UNIVERSITY  OF  CALIFORNIA 
AT  LOS  ANGELES 


GIFT  OF  CAPT.  AND  MRS. 
PAUL  MCBRIDE  PERIGORD 


HEALTH  AND  DISEASE 

THEIR  DETERMINING  FACTORS 


BY 


ROGER   I.   LEE,   M.D. 


PROFESSOR   OF   HYGIENE   IN   HARVARD    UNIVERSITY 

VISITING   PHYSICIAN,   MASSACHUSETTS 

GENERAL   HOSPITAL 


BOSTON 

LITTLE,   BROWN,   AND   COMPANY 
1917 

138139 


Copyright,  1917, 
BT  LITTLE,  BBOWTT,  AND  COMPANY. 


All  rights  reierved 
Published,  February,  1917 


Worfoooti 

Set  up  and  electrotyped  by  J.  S.  Gushing  Co.,  Norwood,  Mass.,  U.S.A. 
Presswork  by  S.  J.  Parkhill  &  Co.,  Boston,  Mass.,  U.S.A. 


4 


TO 

THE   ANONYMOUS   GRADUATE   OF   HARVARD 

WHOSE     WISDOM     AND     GENEROSITY    MADE 

POSSIBLE    THE    DEPARTMENT    OF    HYGIENE 

IN  HIS   ALMA   MATER 


PREFACE 

THE  dissemination  of  information  concerning  matters 
of  health  is  not  only  generally  accepted  as  desirable, 
but  such  education  of  the  public  is  the  basis  of  much 
as    of  the  present-day  work  for  better  health.     This  atti- 
cs   tude  is  in  marked  contrast  to  that  which  has  existed 
up  to  the  immediate  present.     In  the  Middle  Ages, 
for  example,  a  medical  treatise  was  issued  in  the  vulgar 
^b.c  tongue,  rather  than  in  Latin,  the  customary  language 
&    of  learning,  and  was  carefully  guarded  lest  it  fall  into 
£-    the  hands  of  the  laity,  in  order  "  that  these  pearls  should 
£   not  be  cast  before  swine."     But  at  the  present  time 
£"    the  medical  profession  is  beginning  to  appreciate  the 
eg   value  of  intelligent  cooperation  on  the  part  of  the  laity 
^j  and  to  respond  to  the  insistent  demands  of  their  non- 
g"  professional  brethren  for  instruction  in  the  preservation 
O  of  health  and  the  avoidance  of  disease.     Through  the 
gradual  education  of  the  public  to  the  possibilities  of 
health  improvement,  within  the  limits  of  a  generation 
the  death  rate  has  decreased  from  thirty-one  in  a 
thousand  of  population  to  slightly  over  thirteen  per 
thousand.     That  this  decrease  may  continue  until  in 
time  we  may  approximate  the  possibilities  suggested 
by  the  knowledge  which  we  have,  the  public  must  be 


viii  PREFACE 

shown  not  only  how  to  improve  the  health  of  the 
individual  biit  also  how  to  improve  that  of  the  commu- 
nity. And  the  two  considerations  cannot  be  separated. 
No  matter  what  state  of  individual  efficiency  in  health 
may  be  obtained,  it  may  prove  entirely  ineffective  or 
worthless  hi  the  event  of  a  breakdown  in  the  community 
hygiene. 

That  the  public  appreciates  the  importance  of  an 
understanding  of  health  is  attested  by  the  undoubted 
success  of  many  books  dealing  with  specific  phases  of 
the  hygiene  of  the  individual  and  the  crowds  which 
throng  to  lectures  on  the  problems  of  health.  Much 
good  has  been  accomplished  through  such  agencies, 
but  the  effort  to  be  popular  is  attended  by  certain 
dangers.  The  endeavor  to  turn  a  catchy  phrase  may 
present  the  temptation  to  be  sensationally  emphatic 
at  the  expense  of  scientific  accuracy,  and  over-positive 
statements  may  give  an  entirely  erroneous  impression 
of  the  facts.  The  use  of  such  striking  slogans  as 
"  Swat  the  fly  and  avoid  disease  "  is  an  illustration. 
The  elimination  of  flies  is  a  fairly  important  health 
measure,  but,  in  point  of  fact,  the  amount  of  disease 
carried  by  flies  is  probably  small.  Again,  it  is  the 
fashion  to  speak  of  all  deaths  from  tuberculosis  as 
preventable.  While  this  may  be  theoretically  true, 
we  cannot  make  it  absolutely  and  practically  so  until 
we  acquire  further  knowledge.  Another  danger  of 
certain  aspects  of  health  publicity  is  the  almost  unavoid- 
able difficulty  of  creating  the  impression  that  one  phase 
of  hygiene  is  all  important.  It  is  self-evident,  for 
example,  that  no  matter  how  excellent  and  scientific 
a  diet  may  be,  it  will  accomplish  little  if  other  phases 
of  hygiene  do  not  receive  attention. 

As  a  matter  of  fact  the  hygiene  of  food,  air,  and  the 
like  depend  upon  simple  principles  which  can  be 
appreciated  by  any  one.  But  to  achieve  anything 


PREFACE  ix 

approaching  excellent  hygiene  these  principles  must  be 
understood.  The  attempt  to  follow  recipes  for  health, 
no  matter  how  excellent,  without  a  knowledge  of  the 
underlying  principles  may,  and  often  does,  result  in 
ludicrous,  if  not  grievous  and  injurious,  fadism. 

The  present  book  has  been  prepared  in  the  belief 
that  a  discussion  of  the  factors  which  determine  health 
and  disease,  in  the  terms  of  the  new  Preventive  Medi- 
cine, would  provide  the  information  which  the  individual 
should  have  to  meet  intelligently  the  health  problems 
of  himself  and  of  the  community  in  which  he  is  a  citizen. 
The  endeavor  has  been  to  present  in  non-technical 
language  the  facts  to  which  medical  science  can  truth- 
fully assent  without  exaggeration  and  without  undue 
emphasis  upon  any  phase  of  any  question.  Further, 
something  of  the  history  of  disease  and  of  medicine 
has  been  presented  in  the  belief  that  such  a  knowledge 
should  be  a  part  of  the  mental  equipment  of  any  well- 
informed  man  or  woman.  The  book  contains,  then, 
the  principles  which  should  guide  an  individual  in  living 
an  effective  life  to  its  allotted  span ;  the  principles  which 
should  govern  a  community  in  facing  its  many  problems 
of  health  and  which  a  citizen  should  know  to  act  intelli- 
gently and  wisely  towards  this  vital  function  of  govern- 
ment, and  something  of  medical  history  and  progress, 
as  well  as  of  the  fields  still  to  be  explored.  This  material 
has  been  based  on  the  assumption  that  the  intelligent 
layman,  who,  after  all,  is  keenly  interested  in  health  and 
disease  in  his  own  person  and  in  his  family,  and  who 
pays  not  only  the  doctor's  bills  for  himself  and  family, 
but  also  his  share  of  the  community's  medical  bills  in 
taxes,  is  entitled  to  a  straightforward  exposition  of 
the  underlying  principles  of  health  and  disease.  He 
desires  and  should  be  allowed  to  share  not  only  in 
medical  knowledge,  but  also  in  medical  ignorance. 
On  the  other  hand,  it  cannot  be  expected  nor  does  it 


x  PREFACE 

seem  desirable  that  the  layman  shall  undertake  to 
diagnose  or  to  treat  the  individual  ailment,  so  all 
detailed  symptoms  of  diseases  and  the  treatment  of 
diseases  have  been  omitted.  The  proper  sphere  of 
activity  for  the  layman  is  cooperation  in  the  prevention 
of  disease,  and  this  can  be  done  only  through  an  under- 
standing of  the  factors  which  determine  health  and 
disease. 

Most  of  the  material  in  the  following  pages  was  first 
presented  in  a  series  of  lectures  before  classes  in  Harvard 
University.  Indeed,  the  difficulty  in  finding  in  any 
available  form  the  facts  to  afford  a  basis  for  the  forma- 
tion of  judgments  on  the  specific  and  general  problems 
of  health  led  to  the  idea  of  giving  in  book  form  this 
summary  of  the  knowledge  that  has  been  gained  from 
scientific  medicine. 

Of  necessity,  from  the  character  of  this  book,  there 
has  been  opportunity  for  the  inclusion  of  no  extended 
amount  of  original  material.  First-hand  sources  of 
all  sorts,  medical  books,  monographs,  and  periodicals, 
have  been  consulted  freely.  The  reports  of  the  Public 
Health  Service  have  proved  a  veritable  mine  of  informa- 
tion. The  reports  of  state  boards  of  health,  particularly 
those  of  Massachusetts,  of  various  commissions,  associa- 
tions, and  committees,  both  in  this  country  and  else- 
where, have  been  consulted  extensively.  Rosenau's 
"  Preventive  Medicine  and  Hygiene  "  and  Harrington 
and  Richardson's  "  Practical  Hygiene  "  have  been  used, 
with  others,  for  general  reference.  On  special  topics, 
Lusk,  Atwater,  Locke,  and  Friedenwald  and  Riihrah 
on  foods;  Keren  on  alcohol;  Gorgas  and  Ross  on 
insect-borne  diseases ;  Oliver,  Thompson,  and  others  on 
occupational  diseases ;  Hoffman  on  cancer,  and  Hazen 
on  water  should,  perhaps,  receive  special  mention. 
On  the  subject  of  sewage  I  have  endeavored  closely  to 
follow  the  views  of  Professor  George  C.  Whipple. 


PREFACE  xi 

I  desire  to  make  acknowledgment  of  my  great  in- 
debtedness to  Mr.  E.  G.  Rich  for  general  editorial  super- 
vision and  for  his  unflagging  cooperation  in  gathering 
and  arranging  the  material  and  preparing  it  for  the 
press. 

ROGER  I.  LEE 

HARVABD  UNIVERSITY, 
January,  1917. 


CONTENTS 

CHAPTER  PAGE 

PREFACE .  vii 

INTRODUCTION 1 

I    HEREDITY 9 

H    FOOD 23 

HI    AIR 74 

IV    THE  SKIN 84 

V    EXERCISE  AND  WORK 94 

VI    ALCOHOL,    TOBACCO,    AND     THE     HABIT-FORMING 

DRUGS 113 

Alcohol 

Tobacco 

Patent  Medicines  and  Secret  Nostrums 

Habit-forming  Drugs 

VII    LIGHT  AND  THE  EYES 135 

VIII    THE  HYGIENE  OF  THE  TEETH  AND  THE  UPPER  AIR 

PASSAGES 141 

IX    THE  HYGIENE  OF  THE  MIND  AND  NERVOUS  SYSTEM    150 
X    THE  COMMUNICABLE  DISEASES  154 


xiv  CONTENTS 

CHAPTER  PAGE 

XI    DISEASES  TRANSMITTED  BY  INGESTION   .        .        .179 

Typhoid  Fever 
Asiatic  Cholera 
Other  Diseases  Spread  by  Ingestion 

XII    THE  AIR-BORNE  DISEASES      .        .        ....    195 

Coughs  and  Colds 

Influenza 

Diphtheria 

Children's  Diseases 

Pneumonia 

Tuberculosis 

Cerebro-Spinal  Meningitis 

Smallpox 

XTTT    DISEASES  TRANSMITTED  BY  CONTACT      .        .        .    242 

Local  Sepsis 
Tetanus 
Rabies 
Hookworm  Disease 

XTV    THE  VENEREAL  DISEASES  AND  SEX  HYGIENE        .    250 

Syphilis 
Gonorrhea 
Chancroid 
Sex  Hygiene 

XV    THE  INSECT-BORNE  DISEASES          ....    271 

Yellow  Fever 

Malaria 

Bubonic  Plague 

Typhus  Fever 

Filariasis 

Dengue 

Sleeping  Sickness 

Diseases  Caused  by  Ticks 

Leischmaniasis 


CONTENTS  xv 

CHAPTER  PAGE 

XVI    DISEASES  IN  WHICH  THE  METHOD  OF  SPREAD  is 

UNKNOWN 286 

Infantile  Paralysis 
Leprosy 

XVII    GENERAL  CONSIDERATIONS  IN  COMMUNICABLE  DIS- 
EASES   291 

XVD3     CANCER 301 

Instructions  on  Prevention  of  Cancer 

XIX    MILK 305 

XX    WATER 316 

XXI    SEWAGE 328 

Refuse  and  Garbage  Disposal 

XXH    OCCUPATIONAL  DISEASES 333 

XXin    THE  FUNCTION  OP  THE  BOARD  OF  HEALTH    .        .  346 

XXIV     VITAL  STATISTICS 352 

APPENDIX 355 

INDEX                                       359 


HEALTH  AND  DISEASE 


INTRODUCTION 

WHILE  the  laws  of  health  and  disease  are  as  firmly 
fixed  and  as  immutable  as  the  other  laws  of  Nature, 
they  cannot  be  stated  as  yet  in  positive  and  definite 
terms.  Our  knowledge  of  these  complex  laws  is  far 
too  incomplete  for  us  to  grasp  even  all  of  the  salient 
points,  to  say  nothing  of  many  of  the  details.  In  the 
main,  however,  the  underlying  principles  of  the  laws  of 
health  and  disease  have  been  disclosed  and  have  been 
tested  and  proven  by  experience. 

The  health  of  the  individual  depends  upon  many 
factors,  although  all  may  be  classified  in  two  groups, 
heredity  and  environment.  While  in  some  instances 
heredity  is  the  predominating  factor,  in  more  environ- 
ment is  the  determining  factor  in  the  life  of  the  in- 
dividual even  to  the  extent  of  modifying  the  influence 
of  heredity. 

The  influence  of  environment  upon  the  health  of  the 
individual  is  extremely  complex,  and  its  component 
factors  are  many  and  overlapping.  Necessarily  these 
factors  vary  in  importance,  although  we  do  not  yet 
know  the  relative  influence  of  all  of  them.  A  few  of 
these  determining  factors  are  absolute,  but  there  are 
many  others  of  less  potency,  which,  especially  when 
collective,  contribute  definitely  towards  making  for 
health  and  disease.  Certain  of  these  factors  can  be 
controlled  by  the  individual  himself,  —  that  is  by  his 

1 


2  HEALTH  AND  DISEASE 

personal  habits,  —  while  others  can  be  controlled  only 
by  groups  of  individuals,  i.e.  the  community.  Still 
other  factors  cannot  be  controlled  in  the  light  of  our 
present  knowledge. 

Theoretically  all  disease  is  preventable.  Such  an 
assumption,  however,  implies  the  complete  knowledge  of 
the  causes  and  determining  factors  of  disease  and  the 
application  of  that  knowledge.  This  is  an  ideal  state 
of  affairs  which  is  far  removed  from  actual  practice, 
although  it  is  true  that  our  knowledge  concerning  disease 
is  far  ahead  of  our  application  of  it.  In  1915  there  were 
909,155  deaths  reported  in  the  registration  area  of  the 
United  States  (about  two-thirds  of  the  total  popula- 
tion). With  these  figures  as  a  basis,  statisticians  have 
estimated  that  there  are  yearly  in  the  entire  United 
States  over  600,000  deaths  which  might  have  been 
prevented ;  that  over  a  billion  dollars  is  wasted  annu- 
ally through  unnecessary  illness  and  premature  death, 
and  that,  on  the  average,  fifteen  years  of  life  are  lost 
through  the  lack  of  application  of  the  available  knowl- 
edge concerning  health  and  disease. 

To  conserve  all  these  lives  would  necessitate  the  ideal 
application  of  our  knowledge.  Such  an  ideal  is  prob- 
ably impossible  of  attainment;  nevertheless,  such 
statements  illustrate  the  effect  of  the  failure  to  dissemi- 
nate and  apply  the  knowledge  at  hand.  The  re- 
sponsibility for  this  unfortunate  failure  is  to  be  divided 
among  the  experts,  the  community,  and  the  individual. 
Only  cooperative  activities  will  insure  the  desired 
results.  The  whole  conception  of  the  prevention  of 
disease  is  new.  It  is  new  because  the  necessary  knowl- 
edge upon  which  the  prevention  of  disease  is  based  is  new. 
Now  it  is  necessary  to  reconstruct  the  primitive  instinct 
for  self-preservation  on  the  firm  and  rational  foundation 
of  disease  prevention  and  health  preservation. 

Until  recent  years  man  was  almost  defenseless  against 


INTRODUCTION  3 

disease.  Here  we  are  faced  by  the  biological  fact  that 
man  is  governed  by  the  same  instinct  of  preservation 
which  is  so  dominant  in  all  animals.  Coincident  with 
the  mental  development  of  man  came  a  deterioration 
of  the  special  senses  that  go  so  far  in  protecting  animals. 
The  civilization  of  man  introduced  new  problems  of 
health  and  disease.  The  herding  of  individuals  in 
cities,  the  specialized  industries,  the  necessary  trans- 
portation of  food  and  drink  have  drawbacks  in  in- 
creased exposure  to  disease.  Furthermore,  man  suffers 
from  many  diseases  which  are  peculiar  to  his  species  and 
are  not  found  in  the  lower  animals.  In  spite  of  his 
superior  intelligence  man  has  less  defense  against  disease 
than  have  the  lower  animals.  Then,  too,  for  many 
years  his  energies  were  devoted,  almost  exclusively, 
to  the  cure  of  disease  rather  than  to  its  prevention. 
At  times,  inspired  by  blind  fear,  man  fled  pestilence, 
and  this  may  be  said  to  represent  the  origin  of  the 
prevention  of  disease  by  quarantine  and  isolation. 

Out  of  ignorance  there  grew  up  superstitions  and  cus- 
toms which  in  part  regulated  the  habits  and  life  of  man. 
Some  of  these  were  sound,  while  others  were  definitely 
harmful.  Many  of  these  customs  finally  became 
securely  incorporated  in  religious  beliefs.  Thus  the 
Mosaic  Law  gives  instructions  on  habits  of  life,  instruc- 
tions which  are  sound  from  the  viewpoint  of  hygiene. 
But  man  regulated  his  life  in  accordance  with  his  reli- 
gious beliefs,  his  customs,  or  his  desires. 

Then  came  the  growth  of  all  the  sciences  and  the 
birth  of  medical  science.  But,  in  general,  people 
still  regarded  medical  science  as  only  applicable  to 
the  care  and  cure  of  the  sick.  Slowly,  however,  the 
true  instinct  of  self-preservation  began  to  assert  itself. 
The  preservation  of  life  was,  manifestly,  the  preser- 
vation of  health.  Equally  obviously  the  preservation  of 
health  was  the  avoidance  or  the  prevention  of  disease. 


4  HEALTH  AND  DISEASE 

Within  the  past  forty  years  medical  science  has  made 
prodigious  strides  in  solving  the  mysteries  of  health  and 
disease.  Hardly  a  year  has  passed  without  some  dis- 
covery that  has  saved  or  prolonged  life.  As  a  result 
we  have  acquired  a  considerable  knowledge  of  disease, 
its  causation,  and  its  prevention.  While  there  is  still 
much  ignorance  and  many  problems  remain  to  be 
solved,  it  is  not  unreasonable  to  expect  that  the  next 
forty  years  will  see  as  great  an  advance  in  our  knowledge 
as  the  past  forty. 

Exactmedical knowledge is  derivedJiom  ajamLtitude 
of  sources.  Every  science  has  been  drawn  jipon_to 
contribute  its  share.  Chemistry  has  solved  the  mystery 
ofthe  air  we  breathe,  has  analyzed  our  food  and  drink, 
our  blood,  our  organs,  and  our  excretions.  Physics 
has  given  to  us  the  microscope,  the  necessary  imple- 
ment of  exact  medical  information,  the  Roentgen  ray, 
and  other  products  of  electricity.  Bacteriology  has 
revealed  many  of  the  minute  organisms  which  cause 
the  communicable  diseases.  The  engineering  sciences 
have  accomplished  the  purification  of  water  and  the  safe 
disposal  of  sewage.  And  so  the  list  could  be  extended. 
Scientific  medicine  has  taken  from  all  the  sciences. 
It  is  impossible  to  ascribe  to  any  science  or  to  any  source 
its  exact  influence  in  shaping  medical  science  and  pre- 
ventive medicine. 

Three  methods  of  investigation  through  the  utiliza- 
tion of  the  various  sciences  have  made  possible  our 
present  knowledge  of  health  and  disease.  These 
methods  are  the  dissection  of  the  body  after  death, 
animal  experimentation,  and  the  study  of  vital  and 
morbidity  statistics. 

Human  anatomy  and  physiology  are  wonderfully 
contrived.  The  vital  organs  are  so  situated  in  the 
interior  of  the  body,  carefully  protected  by  external 
structures  against  ordinary  accidents,  that  the  examina- 


INTRODUCTION  5 

tion  of  the  exterior  gives  but  little  clue  of  the  wonderful 
mechanism  within.  In  order  to  understand  the  internal 
machinery,  it  is  necessary  that  it  be  examined  with  the 
minutest  care.  The  very  existence  of  the  heart,  to  say 
nothing  of  its  detailed  structure,  would  be  unknown 
without  the  dissection  of  the  human  body.  The  prej- 
udice against  such  dissection  is  perhaps  natural,  but 
in  no  other  way  can  a  knowledge  of  the  internal  mecha- 
nism of  the  body  be  obtained.  In  the  case  of  disease 
this  examination  is  even  more  important.  We  diagnose 
positively  heart  disease,  pneumonia,  typhoid  fever, 
tuberculosis,  internal  cancer,  and  Bright's  disease 
because  we  recognize  a  certain  train  of  symptoms,  a 
certain  group  of  manifestations  by  external  signs  which 
have  been  shown  by  post-mortem  examinations  in  the 
past  to  be  associated  with  those  actual  organic  changes. 
The  accuracy  of  the  diagnosis  depends  solely  on  the 
previous  correlation  of  signs  and  symptoms  during 
life  with  the  actual  conditions  found  after  death.  Care- 
ful post-mortem  examinations  are  constantly  bringing 
new  facts  to  light.  The  problem  of  tuberculosis,  for 
example,  can  now  be  studied  much  more  intelligently, 
since  examination  at  autopsy  has  shown  that  most 
persons  dying  from  other  causes  have  suffered  at  some 
time  in  their  lives  from  a  tuberculous  infection.  So  the 
extension  of  our  skill  and  accuracy  in  diagnosis  depends 
upon  the  continuation  of  the  dissection  of  the  human 
body. 

The  immediate  application  of  the  facts  of  normal 
and  abnormal  anatomy  and  physiology  is  seen  in  the 
physical  examination.  By  careful  examination  the 
skilled  physician  can  detect  abnormality  in  its  incipi- 
ency.  Many  abnormalities  which  are  incurable  in  the 
advanced  stages  are  curable  when  detected  early. 
Then,  too,  it  often  happens  that  abnormalities  exist 
of  which  the  patient  is  entirely  unaware.  Every 


6  HEALTH  AND  DISEASE 

disease  must  have  its  beginning  and  the  onset  of 
symptoms  that  attract  the  patient's  attention  is 
usually  delayed  until  considerable  progress  has  been 
made. 

From  any  point  of  view  it  is  desirable  that  all  per- 
sons should  have  periodic  complete  physical  examina- 
tions. For  the  individual's  own  welfare  it  is  essential 
that  abnormalities  be  detected  and  corrected  or  con- 
trolled if  possible.  For  the  welfare  of  the  community 
it  is  necessary  to  detect  and  prevent  the  further  dis- 
semination of  any  communicable  disease.  Lastly, 
for  the  increase  of  knowledge  of  health  and  disease  by 
which  every  one  benefits,  the  cumulative  data  derived 
from  physical  examinations  enable  the  establishment 
of  accurate  standards  for  normal  and  abnormal  under 
all  conditions  of  life. 

The  second  source  of  information  concerning  health 
and  disease  is  animal  experimentation.  This  experi- 
mentation is  not,  as  is  not  always  realized,  confined 
to  the  lower  animals.  Experimental  fasts  and  diets 
carried  out  by  human  beings  have  largely  solved  many 
problems  of  metabolism.  Man  has  repeatedly  vol- 
unteered for  experimentation,  and  we  have  a  typically 
heroic  instance  in  the  fight  against  yellow  fever.  It 
should  be  emphasized  that  animal  experimentation  is 
by  no  means  synonymous  with  pain  and  suffering. 
Many  of  our  facts  on  heredity  have  been  derived  from 
simple  experiments  in  breeding.  Probably  ninety-nine 
per  cent  of  the  experiments  on  the  lower  animals  consist 
in  inoculations,  which,  with  the  less  sensitive  nervous 
systems  of  such  animals,  produce  less  pain  than  a  simple 
pricking  of  the  finger  by  a  pin.  In  the  remaining 
one  per  cent,  the  experimentation  is  almost  always 
carried  out  under  the  influence  of  anesthetics  with  the 
same  surgical  asepsis  which  characterizes  operations  on 
human  beings. 


INTRODUCTION  7 

Before  the  birth  of  medical  science,  practically  every 
therapeutic  procedure  was  an  experiment  on  the 
patient.  Now  there  is  no  disease  of  which  we  have 
any  knowledge  to  which  carefully  controlled  experi- 
ments on  the  lower  animals  have  not  contributed. 
Furthermore,  in  perhaps  a  more  positive  and  convincing 
fashion,  important  cures  and  preventive  measures,  as 
diphtheria  antitoxin,  smallpox  vaccine,  and  the  like, 
depend  solely  on  animal  experimentation. 

Man  uses  the  lower  animals  for  food,  to  carry  bur- 
dens, or  for  companionship,  or  sport,  purposes  as 
naturally  repugnant  as  animal  experimentation.  Cus- 
tom and  human  needs  have  permitted  all  these  practices 
under  proper  conditions,  and  it  would  seem  self-evident 
that  the  use  of  animals  for  the  saving  of  human  life  is 
equally  justifiable. 

Vital  and  morbidity  statistics,  or  the  bookkeeping  of 
health  and  disease,  are  always  a  fund  of  information. 
While  the  importance  of  reliable  vital  and  morbidity 
statistics  is  hardly  fully  appreciated,  yet  the  imperfect 
records  of  the  past  have  helped  to  solve  many  problems 
of  disease.  Without  statistics  the  size  and  scope  of  a 
problem  cannot  either  be  understood  or  intelligently 
attacked.  Every  individual  and  every  community  has 
the  right  to  be  protected  as  far  as  the  experiences 
of  other  individuals  and  other  communities  make 
possible. 

Many  old  problems  of  health  and  disease  remain  to 
be  stCTvecl,  and  newproBfemy  are  a 


Medical  science,  in  its  broadest  sense,  will  continue  to 
exact  contributions  from  all  possible  sources.  With 
the  growth  of  communities  the  engineering  sciences 
must  be  called  upon  to  solve  many  problems  of  municipal 
sanitation.  The  special  sciences  will  doubtless  furnish 
other  instruments  and  much  special  knowledge.  In  the 
last  analysis,  however,  knowledge  of  man,  particularly 


8  HEALTH  AND  DISEASE 

of  his  health,  will  be  derived  from  the  study  of  man, 
from  the  records  of  man — vital  and  morbidity  statistics 
—  from  observations  of  man,  both  in  health  and  disease, 
proven  by  examination  after  death  or  by  experimenta- 
tion. 


CHAPTER  I 

HEREDITY 

Heredity  versus  Environment.  Among  the  many 
determining  factors  of  health  and  disease  there  is,  in 
the  case  of  each  individual,  one  factor  which  cannot  be 
altered.  This  is  the  factor  of  heredity.  We  cannot 
choose  our  ancestors,  nor,  try  as  they  will,  can  our 
parents  change  certain  characteristics  of  mind  and 
body  which  they  hand  down  to  us.  Sex,  racial  and 
family  peculiarities,  the  red  skin  of  the  Indian,  the 
black  skin  of  the  Negro,  the  eye  of  the  Oriental,  the 
Hapsburg  chin  are  all  manifestly  predetermined  and 
beyond  the  reach  of  human  influence. 

We  come  into  the  world  with  certain  mental  and 
physical  characteristics  which,  however  much  environ- 
ment may  tend  to  develop  or  suppress,  are  our  birth- 
right to  which  or  from  which  we  cannot  add  or  subtract. 
Some  of  the  more  potent  of  these  characteristics  will 
be  evident  and  will  play  a  dominant  role  in  our  lives, 
irrespective  of  the  conditions  of  existence.  Even  the 
most  potent,  however,  are  probably  susceptible  to 
some  modification  through  the  influences  which  we 
characterize  as  environment.  Not  all  of  these  char- 
acteristics will  be  manifested,  either  through  lack  of 
development  or  through  training,  under  the  conditions 
of  life,  of  opposite  acquired  characteristics.  Thus  we 
can  conceive  of  a  great  potential  pianist  who  never 
knows  a  piano,  or  of  the  puny  child  of  delicate  parents, 
who  may  grow  into  vigorous  manhood  through  in- 

9 


10  HEALTH  AND  DISEASE 

telligent  care  of  his  body,  or  of  the  person  with  an 
inheritance  of  placid  temper  which  may  become  acrid 
and  irritable  through  association  in  youth  with  persons 
of  unbalanced  nervous  systems  or  through  a  multiplicity 
of  adversities  through  life.  But  as  we  analyze  the 
evidence  for  and  against  the  inheritance  of  character- 
istics, we  find  a  much  smaller  number  which  are  im- 
mutable than  is  popularly  and  commonly  supposed. 

We  know  that  nutrition  and  exercise  have  a  pro- 
found influence  on  physique,  and  that  education, 
training,  and  association  have  even  a  greater  influence 
on  the  mind  and  character.  All  such  post-natal  in- 
fluences we  group  together  under  the  general  term  of 
environment.  It  is  at  once  evident  that  as  a  child 
imitates  the  mode  of  life  of  the  father,  the  child  will 
tend  to  reflect  the  same  results  of  the  environment 
as  the  father.  A  child,  for  example,  may  imitate  the 
outbursts  of  temper  of  the  father  and,  subjected  to 
the  same  exasperating  environment,  may  become  a 
man  subject  to  fits  of  anger.  This  characteristic  may 
be  attributed  to  either  heredity  or  environment. 
Likewise,  the  child  of  studious  parents  may,  if  stu- 
dious, be  said  to  have  derived  this  characteristic  from 
heredity  or  environment.  But  in  the  case  of  a  child 
stolen  by  thieving  gypsies,  who  grows  up  to  be  a  thief, 
environment  must  be  the  determining  factor,  just  as 
in  the  case  of  the  adopted  child  of  an  intellectual 
couple,  who  turns  out  to  be  feeble-minded,  heredity 
must  be  the  determining  factor. 

Light  on  this  most  complicated  relation  between 
heredity  and  environment  is  extremely  important, 
since,  for  the  future  of  the  race,  it  is  highly  desirable 
to  know  what  characteristics  of  mind  and  body  are 
transmissible  by  inheritance  and  what  are  dependent 
on  environment.  It  is  necessary  to  ascertain  as 
minutely  as  possible  what  characteristics  of  mind  and 


HEREDITY  11 

body  are  not  only  predetermined  but  fixed  and  un- 
alterable, and  what  are  not;  how  to  accentuate,  by 
the  factors  of  heredity  and  environment,  the  good 
characteristics  and  how  to  obscure  the  bad,  and  what 
are  the  results  in  posterity  of  the  mixture  of  prede- 
termined and  acquired  characteristics  in  all  sorts  of 
possible  combinations.  While  it  is  true  that  we  can- 
not modify  the  traits  of  our  ancestors,  yet  by  environ- 
ment we  can  modify  profoundly  our  own  lives  and 
some  of  our  characteristics  and  we  can  attempt  to 
modify  posterity  by  selection  of  the  other  half  of  our 
child's  inheritance. 

Our  sources  of  information  on  the  vast  subject  of 
heredity  are  two.  In  the  first  place  we  have  the  im- 
mense data  of  human  experience  from  which  to  draw. 
Information  from  this  source  is  haphazard  and  un- 
scientific, since  carefully  controlled  experiments  in 
human  breeding  are  not  possible.  Our  second  source 
of  information  is  through  experiments  on  plants  and 
animals,  and  through  such  experiments  some  of  the 
fundamental  factors  in  heredity  have  been  disclosed. 
Yet,  while  accurate  observations  can  be  made  and 
final  conclusions  drawn  which  are  true  for  plants  and 
animals,  it  is  not  possible  to  transfer  all  the  details 
to  the  peculiar  and  the  more  complicated  problem  of 
heredity  in  the  human  being. 

The  Accumulated  Data  of  Hitman  Heredity. 
From  time  immemorial  the  classic  controversy  over 
the  relative  influence  which  heredity  and  environment 
play  in  determining  physical  and  mental  characteris- 
tics has  continued.  The  believers  in  the  supreme 
importance  of  heredity  have  been  represented  by  the 
aristocrats,  while  the  contenders  for  environment  have 
been  represented  by  the  common  people.  The  So- 
cialists of  to-day,  for  instance,  believe  in  the  predomi- 
nating influence  of  environment,  while  to  the  aristocrat 


12  HEALTH  AND  DISEASE 

heredity  means  everything.  The  aristocrat  maintains 
that  one  can  only  be  born  a  gentleman  and  that  on 
birth  depends  a  man's  intellectual  and  social  status. 
In  his  arrogance  of  birth  he  attributes  to  it  many 
qualities  which  are  definitely  the  product  of  aristo- 
cratic environment. 

Our  knowledge  of  heredity  has  consisted  for  a  long 
time  of  a  number  of  isolated  facts.  It  has  been  well 
known  that  large  people  breed  large  children.  The 
transmission  of  such  family  characteristics  as  light 
hair,  blue  eyes,  and  a  general  resemblance  is  well 
recognized.  It  is  generally  accepted  that  colored 
people  will  breed  colored  children,  and  that  the  min- 
gling of  colored  and  white  people  will  produce  a  mixture 
of  colors.  Then  we  know  that  certain  races  are  more 
immune  or  more  susceptible  to  certain  diseases  than 
other  races,  while  a  few  diseases  are  definitely  in- 
herited. It  is  known  that  some  diseases,  gout  and 
hemophilia,  for  example,  occur  regularly  in  certain 
families.  At  one  time  the  belief  in  heredity  was 
carried  so  far  that  it  was  thought  that  such  a  disease 
as  tuberculosis  was  entirely  hereditary.  We  now 
know,  of  course,  that  none  of  the  infectious  diseases 
are  hereditary,  but  are  due  to  contact.  This  contact 
may  occur  in  the  womb,  and  we  speak,  rather  in- 
accurately, of  inherited  syphilis. 

We  have  learned  to  appreciate  and  to  disbelieve  in 
the  transfer  of  gross  bodily  mutilations.  If  a  man  has 
a  leg  cut  off,  for  example,  there  is  not  the  slightest 
chance  that  any  of  his  children  will  lack  a  leg.  We 
have  also  learned  that  it  is  impossible  to  pass  on  by 
inheritance  the  results  of  any  training  of  the  mind  or 
body. 

Many  people  have  believed  in  the  so-called  prenatal 
impressions,  a  favorite  device  of  writers  of  fiction.  It 
was  supposed,  and  is  still  supposed  by  some,  that  the 


HEREDITY     .  13 

mother,  when  carrying  a  child,  could  impress  certain 
things  on  the  child.  This  is  absolutely  impossible,  at 
least  to  a  physical  extent.  Hereditary  influences  are 
consummated  once  and  for  all  in  the  union  of  the 
spermatozoon  and  the  ovum. 

The  Jukes  and  "  Kallikak  "  Families.  We  have 
learned  a  great  deal  about  heredity  through  the  study 
of  families  of  abnormal  individuals.  The  study  of  the 
Jukes  and  so-called  Kallikak  *  families  has  furnished  us 
with  a  large  amount  of  data  which  has  permitted  us 
to  draw  valuable  conclusions.  The  Jukes  family  was 
descended  from  a  lazy  and  irresponsible  backwoods- 
man. As  his  descendants  have  lived  in  New  York 
state  since  1720,  it  has  been  possible  to  study  the 
family  with  considerable  care.  In  five  generations  the 
Jukes'  descendants  numbered  approximately  1,200 
people,  and  the  histories  of  over  a  thousand  of  them 
have  been  worked  out.  Some  three  hundred  died  in 
infancy.  Of  the  remaining,  310  were  paupers  living 
in  almshouses ;  440  were  physical  wrecks  due  to  gross 
irregularities  of  life;  more  than  half  the  women  were 
prostitutes ;  130  were  convicted  criminals ;  sixty  were 
habitual  thieves,  and  seven  were  murderers.  None  of 
the  Jukes  ever  got  a  common  school  education;  only 
twenty  ever  learned  a  trade,  and  ten  of  these  learned 
it  when  in  prison,  where  they  had  no  alternative. 

The  so-called  Kallikak  family  is,  perhaps,  even 
more  suggestive.  Kallikak  was  descended  from  good 
English  stock  and  served  as  a  soldier  in  the  War  of  the 
Revolution.  He  had  sexual  relations  with  a  feeble- 
minded girl,  and  she  bore  him  a  son  who  was  also 
feeble-minded.  This  son  married  a  normal  woman. 
They,  in  turn,  produced  five  feeble-minded  and  two 
normal  children.  From  these  children  have  come 

*  Goddard,  H.  H.,  "  The  Kallikak  Family."     New  York.  1912. 


14  HEALTH  AND  DISEASE 

480  descendants.  Thirty-six  of  these  were  illegiti- 
mate ;  thirty-three  sexually  immoral ;  twenty-four  con- 
firmed alcoholics;  and  three  epileptics.  Eighty-two 
died  in  infancy,  three  were  criminals,  and  143  were 
distinctly  feeble-minded.  Only  forty-six  who  were  ap- 
parently normal  have  been  found. 

After  Kallikak  had  started  this  degenerate  line,  he 
married  a  normal  girl  of  good  ancestry.  From  this 
union  with  a  normal  woman  there  have  been  496 
descendants.  Only  two  of  this  number  showed  any- 
thing but  a  normal  mentality.  Both  exceptions  were 
insane,  probably  due  to  marriage  with  an  outside  stock 
of  insane  tendency.  Not  a  case  of  feeble-mindedness 
appeared  among  the  496;  on  the  contrary,  all  oc- 
cupied positions  in  the  upper  walks  of  life,  and  there 
were  no  criminals  among  them. 

From  this  evidence  it  becomes  obvious  that  feeble- 
mindedness is  not  a  question  of  environment,  but 
largely,  if  not  entirely,  a  matter  of  heredity.  The 
law  of  heredity  is  that  feeble-minded,  who  marry,  will 
have  feeble-minded  children.  Every  child  of  two 
feeble-minded  parents  will  be  feeble-minded. 

Feeble-mindedness.  Feeble-mindedness  is  of  vary- 
ing degree.  In  the  lowest  scale  is  the  idiot ;  next  comes 
the  imbecile,  and  then  the  high  grade  mental  defective, 
who  is  classified  under  the  term,  moron.  The  degree 
of  mental  development  which  constitutes  feeble- 
mindedness has  been  arbitrarily  fixed,  for  an  adult,  as 
that  of  a  child  of  twelve.  By  the  use  of  tests  based 
on  the  principles  first  advocated  by  Binet  and  often 
called  the  Binet-Simon  scale  of  intelligence,  it  is  reason- 
ably simple  to  approximate  the  mental  development 
of  the  feeble-minded  person  in  terms  of  years  up  to 
twelve.  These  tests  merely  consist  of  simple  questions 
and  exercises  appropriate  for  a  child  of  a  given  age. 
The  idiot  is  able  to  do  the  tests  up  to  the  level  of  the 


HEREDITY  15 

normal  child  of  two ;  the  imbecile  the  tests  for  a  child 
between  two  and  seven  years,  and  the  moron  those  of 
a  child  between  seven  and  twelve.  It  is  now  believed 
that  such  tests  are  not  applicable  to  mentalities  cor- 
responding to  children  over  twelve.  While  it  is  thus 
impossible  to  designate  by  examination  as  feeble- 
minded persons  of  manifest  low  mentality  (that  is 
above  twelve  years  of  age),  such  persons,  called  normal, 
are  frequent  in  feeble-minded  families,  and  are  often  a 
menace  to  the  community. 

It  should  be  borne  in  mind  that  feeble-mindedness 
is  entirely  a  mental  characteristic,  for  the  body  of  the 
feeble-minded  person  is  normal  and  often  unusually 
well  developed.  But  despite  the  bodies  and  physical 
ability  of  men  and  women,  the  feeble-minded  are  chil- 
dren, —  they  have  the  minds  of  children  and  are  con- 
trolled by  the  emotions  of  children.  The  anger  of  a 
child  is  impotent  of  physical  harm  through  the  lack 
of  physical  strength;  not  so  the  anger  of  the  feeble- 
minded with  the  powerful  adult  frame.  Hence  we 
read  of  murders  for  trivial  causes,  which  are  inex- 
plicable to  the  adult  mind  and  often  to  the  laws  of 
justice.  No  less  inexplicable  is  the  absence  of  any 
attempt  at  concealment  and  the  absence  of  remorse. 
The  culprit,  adult  in  body,  views  the  affair  with  the 
mental  vision  of  perhaps  eight  years.  Stupid  petty 
burglary  and  arson  are  the  crimes  to  which  the  feeble- 
minded are  prone,  but  the  criminal  bent  of  the  feeble- 
minded is  determined  entirely  by  environment. 

Among  the  feeble-minded  we  see,  perhaps,  best 
illustrated  the  dual  influences  of  heredity  and  environ- 
ment. The  childlike  mind,  free  from  evil  influences 
and  associations,  may  go  through  life  and,  possibly, 
only  be  regarded  as  somewhat  simple.  Complicated 
tasks  and  persistent  endeavor,  especially  in  the  face 
of  obstacles,  are  beyond  the  individual,  but  simple 


16 

physical  work,  under  supervision,  is  easy.  But  the 
chances  favor  childlike  rebellion  against  the  restraint 
of  the  laws  and  customs  of  society.  So  the  fully  de- 
veloped physical  instinct  of  sex  plays  an  important 
r6le  in  the  delinquencies  of  the  feeble-minded.  The 
sexual  desires  are  not  restrained,  and  the  sexual  im- 
moralities of  the  feeble-minded  are  notorious.  Feeble- 
minded women  often  have  physical  attraction  and 
statistics  show  that  they  comprise  between  seventy-five 
and  eighty  per  cent  of  the  public  prostitutes.  So,  too, 
the  feeble-minded  are  frequently  alcoholics  and  other 
drug  habitues.  In  general  they  are  industrial  misfits, 
the  ne'er-do-wells,  the  habitual  loafers  and  "  bums  " 
of  the  community.  They  fill  the  almshouses  as  well 
as  the  jails,  and  even  the  insane  asylums. 

The  high  grade  feeble-minded  person,  the  moron, 
or  the  person  just  above  that  type,  is  a  particular 
problem  of  the  community.  He  transmits  his  defect 
and,  as  a  potential  criminal,  is  a  constant  menace  to 
society.  The  trait  of  feeble-mindedness  may  be  ob- 
scured by  mating  with  a  normal  person,  since  normality 
is  predominant  over  feeble-mindedness,  but  the  trait 
still  persists.  Experience  has  shown  that  such  persons 
cannot  be  allowed  to  roam  at  large.  Sterilization, 
which  has  been  suggested  as  a  remedy  for  the  problem, 
merely  prevents  propagation,  but  not  crime.  Com- 
munities are  slowly  beginning  to  realize  that  it  is  almost 
inevitable  that  such  persons,  depending  on  how  their 
tendencies  are  developed  by  the  peculiar  environment, 
must  eventually  be  supported  in  almshouses,  hospitals, 
asylums,  and  jails.  So  it  is  probably  wiser  and  more 
economical  for  the  community,  as  has  already  been 
accomplished  successfully  in  certain  places,  to  support 
the  feeble-minded  in  segregated  colonies. 

Other  Hereditary  Defects.  Feeble-mindedness,  as 
a  purely  hereditary  characteristic,  is  the  most  im- 


HEREDITY  17 

portant  hereditary  disease  we  know.  While  brain 
injury  and  brain  disease  may  cause  a  deficient  men- 
tality, such  a  defect  is  not  transmitted.  Heredity 
plays  an  important  r61e  in  the  causation  of  other  mental 
abnormalities,  but  in  none,  according  to  our  present 
knowledge,  is  it  the  sole  determining  factor  as  is  the 
case  in  feeble-mindedness.  Nervous  and  mental  in- 
stability of  many  varieties  definitely  run  in  certain 
families.  Heredity,  as  well,  is  the  most  important 
factor  in  determining  certain  types  of  insanity. 

Certain  more  obvious  physical  phenomena  and  con- 
ditions, such  as  short  fingers,  deaf-mutism,  hemophilia, 
albinism,  forms  of  chorea  and  ataxia,  cleft  palate, 
myopia,  and  the  like,  are  peculiarly  present  in  families 
and  are  handed  on  from  generation  to  generation.  We 
have,  furthermore,  the  most  interesting  observation 
that  hemophilia  is  transmitted  only  through  females 
and  only  to  males.  Color-blindness  is  essentially  a 
male  inherited  characteristic. 

But  it  should  not  be  supposed  that  only  the  bad 
traits  are  transmitted  through  inheritance.  Fortu- 
nately for  us  the  studies  of  families  indicate  as  posi- 
tively that  the  good  traits  are  handed  on  with  the  same 
certainty  as  all  the  weaknesses.  Marked  musical  talent, 
generosity,  artistic  bent,  and  similar  qualities  are  essen- 
tially hereditary,  as  well  as  desirable  physical  attributes. 
A  few  notable  families  in  which  many  of  the  descendants 
accomplished  marked  achievements  show  positively 
how  even  intellectual  power  is  inherited.  The  family 
of  Bach  is  an  illustration  of  the  inheritance  of  musical 
talent.  This  family  produced  twenty  eminent  com- 
posers and  twice  as  many  who  possessed  marked 
ability.  The  classical  example  of  the  inheritance  of 
intellectual  power  is  the  family  of  Jonathan  Edwards. 
The  achievements  of  the  1394  descendants  of  this 
eminent  philosopher  have  been  tabulated  by  Kellicott 


18  HEALTH  AND  DISEASE 

in  his  book  on  "  Social  Direction  of  Human  Evolu- 
tion." The  list  includes  "  295  who  were  college 
graduates;  13  presidents  of  our  greatest  colleges; 
65  professors  in  colleges,  besides  many  principals  of 
other  important  educational  institutions;  60  physi- 
cians, many  of  them  eminent;  100  and  more  clergy- 
men, missionaries,  or  theological  professors ;  75  were 
officers  in  the  army  and  navy;  60  prominent  authors 
and  writers,  by  whom  135  books  of  merit  were  written 
and  published  and  18  important  periodicals  edited; 
33  American  states  and  several  foreign  countries,  and 
92  American  cities  and  many  foreign  cities  have  profited 
by  the  beneficent  influences  of  their  eminent  activity ; 
100  and  more  were  lawyers,  of  whom  one  was  our  most 
eminent  professor  of  law;  30  were  judges;  80  held 
public  office,  of  whom  one  was  vice-president  of  the 
United  States ;  3  were  United  States  senators ;  several 
were  governors,  members  of  Congress,  framers  of  state 
constitutions,  mayors  of  cities,  and  ministers  of  foreign 
courts ;  one  was  president  of  the  Pacific  Mail  Company ; 
15  railroads,  many  banks,  insurance  companies,  and 
large  industrial  enterprises  have  been  indebted  to  their 
management.  ...  It  is  not  known  that  any  one  of 
them  was  ever  convicted  of  crime." 

Experimental  Data.  Approximately  all  the  funda- 
mental facts  we  know  about  heredity  are  contained 
in  the  so-called  Mendel's  law.  Mendel  was  an  Aus- 
trian monk  who  conducted  extended  experiments  on 
peas.  In  1866,  he  was  able  to  state  with  definiteness 
some  of  the  considerations  which  govern  the  trans- 
mission of  characteristics.  His  conclusions,  however, 
important  as  they  were,  did  not  receive  the  considera- 
tion which  they  merited  until  the  publication  of  the 
work  of  DeVries,  an  investigator  in  Holland,  in  1899. 
The  essential  factors  in  heredity,  as  stated  by  Mendel, 
are  unit  characteristics,  dominance,  and  segregation. 


HEREDITY  19 

A  unit  characteristic  is  one  that  is  transmitted  from 
parent  to  offspring  through  successive  generations. 
When  parents  with  complementary  unit  characteris- 
tics mate,  it  is  found  that  one  characteristic  pre- 
dominates in  the  offspring.  This  is  dominance.  Thus 
when  Mendel  crossed  giant  and  dwarf  peas,  the  giant 
peas  predominated  in  the  offspring,  since  the  charac- 
teristic of  giantism,  in  this  illustration,  is  dominant 
and  dwarfism  is  recessive.  These  unit  characteristics 
from  the  separate  parents  usually  remain  separate 
and  distinct,  —  segregation.  We  do  not  know  just 
what  is  transmitted  from  parent  to  offspring,  but  it  is 
only  something  which  determines  the  development  of 
the  unit  characteristic,  —  the  determiner. 

A  good  illustration  of  the  Mendelian  law  is  the  in- 
heritance of  color  in  the  Andalusian  fowl  as  worked 
out  by  Bateson.  There  are  two  established  varieties 
of  this  fowl,  —  one  black  and  the  other  white.  Each 
of  these,  by  itself,  breeds  true  to  itself.  Black  mated 
with  black  produce  black  offspring ;  while  white  mated 
with  white  produce  only  white  offspring.  But  if  a 
white  fowl  mates  with  a  black,  the  offspring  will  be 
neither  white  nor  black,  but  a  grayish  color  known  as 
"  blue."  When  these  hybrids  mate  there  are  three 
colors  among  the  offspring,  blue,  white,  and  black. 
Furthermore,  the  proportions  of  each  color  are  fixed, 
for  one-half  will  be  blue,  one-quarter  black,  and  one- 
quarter  white.  In  all  generations,  white  from  white  or 
from  blue  will  always  breed  true  and  so  with  the  black. 
A  pure  race  of  blues  cannot  be  established. 

Guinea  pigs  well  illustrate  the  law  of  dominant  and 
recessive  characteristics.  If  black  and  white  guinea 
pigs  are  mated,  the  offspring  will  all  be  black.  The 
black  is  the  dominant  characteristic  and  the  white  the 
recessive.  These  black  guinea  pigs  are  as  true  hybrids 
as  the  blue  Andalusian  fowl.  If  these  hybrid  guinea 


20  HEALTH  AND  DISEASE 

pigs  are  mated,  all  the  offspring  will  not  be  black,  but 
three-quarters  will  be  black  and  one-quarter  white. 
Some  of  the  blacks  will  breed  true,  while  others, 
apparently  like  their  black  brothers  and  sisters,  never- 
theless contain  the  white  taint,  and  so  will  breed  one- 
quarter  white. 

The  same  principles  of  heredity  hold  true  for  human 
beings,  although  it  is  difficult  to  work  this  out,  as  we 
can  rarely  get  sufficient  details  concerning  our  ances- 
tors. But  we  do  see  striking  illustrations  of  Mendel's 
law  in  the  transmission  of  disease.  The  difficulty  in 
applying  the  law  is  to  determine  dominance.  We 
know,  however,  that  normality  is  dominant  over  feeble- 
mindedness and  insanity,  and  that  Huntington's 
chorea  is  dominant  over  normality,  and  black  eyes 
over  blue  eyes. 

A  further  complication  presents  itself  in  the  fact 
that  all  characteristics  are  not  unit  characteristics. 
In  other  words,  instead  of  maintaining  the  two  original 
characteristics  and  one  hybrid  type,  we  get  blending, 
as  seen  in  the  varying  shades  of  color  of  the  skin  in  the 
mixed  negroes  and  whites.  As  we  have  seen,  heredity 
simply  governs  the  proportions  of  the  ultimate  de- 
scendants. So  the  studies  of  human  heredity  are 
complicated  by  a  small  number  of  children.  While 
the  chance  for  the  appearance  of  a  certain  characteristic 
is  fixed  numerically,  we  may  not  be  able  to  fix  the 
status  of  the  individual  child  until  we  have  had  an 
opportunity  to  study  the  progeny.  We  may  see,  there- 
fore, in  the  single  child  the  outcome  of  at  least  three 
possibilities,  and  this  outcome  may  be  happy  or  tragic 
in  his  person,  or  in  his  progeny. 

Inbreeding.  Inbreeding,  or  the  mating  of  people 
with  the  same  characteristics,  is  a  hazardous  experi- 
ment. This  is  illustrated  by  the  problem  of  the  mar- 
riage of  cousins.  The  objection  to  such  marriages 


HEREDITY  21 

rests  entirely  on  this  question  of  heredity.  Any  defect 
in  the  inheritance,  such  as  a  strain  of  insanity,  wijji 
become  intensified  in  the  offspring  by  such  a  marriage. 
The  intermarriage  does  not  create  the  defects,  but 
simply  brings  them  to  the  light.  Cross-breeding  does 
not  remove  defects  of  inheritance ;  it  only  hides  them. 
If  an  insane  person  is  married  to  a  person,  apparently 
normal,  but  with  a  taint  of  insanity  in  the  family,  the 
probabilities  are  that  some  of  the  children  will  be  in- 
sane. If,  however,  the  person  with  a  strain  of  insanity 
marries  into  a  rugged  stock,  the  defect  will  tend  to 
be  obscured,  although  there  is  a  chance  that  the  in- 
sanity may  crop  out  again  in  a  later  generation. 

The  study  of  the  results  of  inbreeding  in  many 
localities  shows  exactly  what  we  should  expect.  Con- 
sanguinity on  Martha's  Vineyard  shows  eleven  per  cent 
deaf  mutes;  on  Point  Judith  thirteen  per  cent  idiots 
and  seven  per  cent  insane ;  in  the  Bahamas  the  result 
is  idiocy  and  blindness ;  in  a  community  on  Chesapeake 
Bay  dwarfness  in  stature,  and  on  a  Maine  island 
stupidity. 

The  possibility  of  the  inheritance  of  acquired  charac- 
teristics, which  are,  of  course,  due  to  environment,  is 
denied  by  present-day  scientists,  although  the  belief 
in  such  inheritance  has  existed  from  the  earliest  times. 
If  any  acquired  characteristics  are  ever  passed  on,  it  is 
done  very,  very  slowly. 

In  regulating  our  lives  we  should  appreciate  that 
heredity  is  a  fundamental  factor  in  our  physical  and 
mental  makeup.  The  transmission  of  defects,  ex- 
cellences, and  tendencies  is  fully  recognized.  Training 
and  good  habits  can  go  far  towards  developing  desirable 
traits  and  suppressing  those  that  are  undesirable.  We 
should,  therefore,  so  adjust  our  mode  of  living  as  to 
make  the  most  effective  use  of  our  bodily  and  mental 
equipment.  While  as  yet  the  knowledge  of  the  com- 


22  HEALTH  AND  DISEASE 

plexities  of  human  heredity  is  not  sufficiently  complete 
or  positive  to  justify  marriage  on  the  sole  basis  of 
genetics,  nevertheless  the  data  at  hand  may  well  be 
an  influencing  factor  for  those  who  desire  to  hand  down 
to  the  next  generation  a  good  inheritance  of  mind  and 
body. 


CHAPTER  II 

FOOD 

Nutrition.  Our  scientific  knowledge  of  the  subject 
of  nutrition  has  been  gained  only  within  recent  years. 
We  have  had,  of  course,  a  vast  amount  of  empirical 
information  on  the  subject,  the  result  of  the  experience 
of  the  homekeepers  of  the  ages.  Such  information, 
as  is  always  the  case  with  facts  discovered  in  this  way, 
has  been  combined  with  superstitions  and  old  wives' 
tales,  as,  for  instance,  that  a  fish  diet  was  conducive  to 
brain  development,  or  the  equally  widespread  belief 
that  fish  was  the  cause  of  leprosy.  The  whys  and 
wherefores  of  the  vital  function  of  nutrition  have  been 
learned  only  very  recently  indeed. 

In  the  scientific  studies  which  have  been  made  on  this 
subject  it  has  been  found,  however,  that  the  facts  based 
on  empiricism,  as  exemplified  by  the  everyday  table, 
correspond  reasonably  closely  to  the  facts  based  on 
science.  And,  furthermore,  while  different  peoples 
and  races  apparently  vary  widely  in  their  diets,  scien- 
tific analysis  shows  an  actual  striking  similarity.  Just 
as  cattle  will  range  far  for  salt,  and  every  animal  feels 
the  need  of  water,  so  the  natural  instinct  tends  to  con- 
trol not  only  the  amount  of  nourishment  in  the  food, 
but  also  the  appropriate  balance. 

Nutrition  is  life,  for  on  it  depends  the  existence  as 
well  as  the  growth  of  the  body,  from  food  we  derive 
the  necessary  energy  for  the  physical  and  mental  work 

Which  the  body  lias  to  do,  and,  likewise,  from  food  are 

__ .  . ..  23 


24  HEALTH  AND  DISEASE 

elaborated,  in  some  mysterious  fashion,  those  substances 
which  give  the  body  the  ability  to  resist  and  overcome 
disease.  Through  proper  nutrition  only  can  we  reach 
the  maximum  of  physical  and  mental  efficiency,  avoid 
disease,  and  maintain  what  we  know  as  health. 

Nutrition  is  accomplished  by  the  use  of  foods  which 
are  taken  into  the  body  through  the  mouth  and  which, 
through  the  processes  of  digestion,  are  transformed  into 
tissue-building  material  and  into  heat,  or  into  its  equiva- 
lent, energy.  In  general  we  consider  as  food  only  such 
substances  as  can  be  oxidized  in  the  body.  However, 
water  and  air  are  also  absolutely  necessary  for  the  pro- 
cess of  nutrition. 

Processes  of  Nutrition.  The  physiology  and  the 
chemistry  of  the  changes  through  which  whatever 
we  put  into  our  mouths  as  food  passes  in  order  to  be 
made  into  appropriate  new  tissue  as  growth  or  repair 
or  into  energy  of  mind  or  body  is  complicated  and 
wonderful.  Science  has  not  yet  succeeded  in  solving 
all  the  intricacies  of  these  mysterious  processes.  Many 
of  them  can  be  repeated  in  the  test  tube,  but  no  artificial 
creation  can  compare  with  the  methods  of  Nature  .in 
handling  food.  Despite  the  endeavors  of  science  and 
trade  the  human  race  is  practically  entirely  dependent 
on  the  natural  physiology  and  chemistry  of  digestion. 
Neither  tissue  nor  energy  can  be  manufactured  outside 
of  the  body,  so  that  our  predigested  foods  are  in  fact  a 
fiction.  The  crowning  achievement  of  scientific  feed- 
ing is  to  replace  lost  blood  by  new  blood,  not  manufac- 
tured artificially,  but  from  another  person. 

Furthermore,  there  has  been  little  success  attained 
in  feeding  in  any  other  way  than  through  the  mouth. 
It  is  true  that  water  can  be  absorbed  when  administered 
by  rectum  (the  discharging  end  of  the  intestinal  canal), 
also  under  the  skin,  and  into  the  veins.  Certain  food 
substances,  in  limited  amounts,  can  be  absorbed  in  these 


FOOD  25 

three  ways.  Unfortunately,  however,  the  total  amount 
of  nourishment,  excluding  water,  which  can  be  admin- 
istered and  oxidized  in  any  other  way  than  through  the 
mouth,  is  so  small  as  to  be  negligible  as  a  method  of 
sustaining  life  for  any  considerable  period  of  time.  In 
other  words,  we  do  not  possess  the  key  to  Nature's  secret 
of  preparing  food  for  actual  use  and  now,  after  years  of 
research,  we  are  still  entirely  dependent  upon  taking 
through  the  mouth  food,  only  modified  by  the  details 
of  custom,  taste,  and  health,  from  the  natural  supply. 
The  day  of  the  concentrated  tabloid  of  energy  is  still 
far  distant. 

Food  Analysis.  In  contrast  to  our  lack  of  progress 
in  discovering  the  key  to  the  processes  of  nutrition,  we 
have  made  enormous  strides  in  the  study  of  foods  so 
far  as  their  analysis  goes.  We  now  know  that  much 
which  we  eat  has  no  food  value,  i.e.  cannot  be  converted 
into  tissue  or  heat.  We  can  also  determine  how  ap- 
parently similar  foods  differ  in  furnishing  different 
elements  to  the  body.  In  general  we  refer  to  a  food  as 
having  so  much  food  value.  This,  however,  does  not 
take  into  consideration  either  the  water  or  certain  other 
factors,  but  represents  the  intrinsic  value  of  a  given  food 
in  the  production  of  tissue  or  heat.  The  determination 
of  such  food  values  depends  upon  the  fact  that  our  food 
has  to  be  oxidized,  —  that  is  burnt,  much  in  the  same 
way  that  wood  and  gas  are  burnt.  For  this  process 
oxygen  is  absolutely  essential.  By  means  of  a  specially 
designed  chamber,  called  a  calorimeter,  where  in- 
dividuals can  live  for  purposes  of  experiment,  it  is 
possible  to  measure  accurately,  in  terms  of  heat,  the 
food  taken,  as  we  would  measure  the  heat  of  a  sub- 
stance directly  burnt. 

Through  the  work  of  various  scientists  we  are  now 
able  to  speak  pretty  definitely  not  only  of  the  amounts 
of  foods  which  the  body  must  have,  but  also  of  the 


26  HEALTH  AND  DISEASE 

kinds  of  food  required.  We  know  the  precise  constit- 
uents of  the  different  foods  and  the  particular  use  and 
value  of  a  given  food.  It  is  fairly  well  determined  that, 
in  general,  there  are  two  classes  of  foods,  —  one  of  which 
builds  up  tissues  and  the  other  of  which  serves  as  fuel. 
The  fuel  is  utilized  in  two  ways  —  as  energy  and  heat. 
Approximately  one-tenth  of  our  food  goes  to  build  up  or 
replace  tissue,  while  nine-tenths  is  used  as  fuel.  Even 
in  quiet  sleep  the  heart  beats,  breathing  continues,  the 
involuntary  movements  and  the  chemical  processes 
of  digestion  are  taking  place,  and  these  processes  must 
be  activated  by  fuel.  In  addition,  the  body  must  be 
kept  warm.  So  it  is  estimated  that  only  twenty  per 
cent  of  the  food  is  used  up  in  what  we  know  as  volun- 
tary bodily  activity. 

Foodstuffs.  In  the  study  of  food  we  find  five 
groups  of  foodstuffs,  —  water,  mineral  matter  or  ash, 
proteins,  carbohydrates,  and  fats.  The  first  two, 
water  and  mineral  matter,  while  absolutely  necessary 
to  life,  are  not  oxidized,  and  so  form  no  part  of  the 
heat-producing  elements. 

Water.  Water  is  the  most  important  constituent 
of  diet,  as  without  it  a  person  can  live  for  only  a  short 
time,  —  about  five  days.  On  the  other  hand,  experi- 
mental fasts  have  lasted  for  thirty  days,  but  in  such 
fasts  water  was  taken.  The  importance  of  water  to 
life  is  better  understood  when  we  consider  that  the  body 
is  composed  of  from  sixty  to  seventy  per  cent  of  water 
and  that  the  amount  which  it  throws  off  as  waste  has 
to  be  replaced  through  the  processes  of  nutrition. 
Under  conditions  of  profuse  sweating  the  body  is  drained 
of  water  and  this  must  be  replenished.  The  same  holds 
true  in  cases  of  profuse  diarrhea.  Perhaps  the  best 
guide  to  the  amount  of  water  which  is  necessary  for  our 
well-being  is  found  in  the  daily  amount  of  urine.  This 
should  be  1,500  cc.  or  three  pints  and  represents  the 


FOOD  27 

residue  after  water  has  been  extracted  for  all  other 
functions.  The  average  person,  therefore,  should  con- 
sume from  two  to  four  liters  or  quarts  of  water  a  day. 
But  this  supply  need  not  be  taken  as  water.  All  foods 
contain  some  water,  and  the  ordinary  individual  gets 
considerable  quantities  in  such  things  as  fruits  and 
vegetables,  not  to  mention  the  obvious  liquids,  —  milk, 
tea,  coffee,  and  soup.  The  habits  of  rabbits  throw  a 
light  on  the  relation  of  vegetables  of  high  water  content 
to  the  amount  of  water  required  by  the  system.  Rab- 
bits which  live  on  carrots  and  greens,  both  of  which 
contain  a  large  proportion  of  water,  are  never  seen  to 
drink  water.  They  get  sufficient  in  their  food.  If 
rabbits  are  fed  on  oats,  they  drink  water  in  considerable 
quantities. 

The  amount  of  water  'taken  into  the  system  has  a 
marked  effect  in  regulating  the  proper  functioning  of 
the  kidneys  and  digestive  processes.  An  insufficient 
water  intake  is  frequently  an  important  aggravating 
cause  of  constipation.  Many  people,  especially  women, 
deliberately  form  the  habit  of  greatly  diminished  fluid 
intake  in  order  to  eliminate  the  possible  embarrassment 
of  being  compelled  to  respond  to  the  periodic  demands 
of  Nature  which  arise  when  sufficient  water  is  taken. 
Such  a  practice  is  closely  associated  with  insufficient 
flushing  of  the  entire  system.  If  such  a  condition 
arises,  certain  deleterious  substances  may  be  left  in  the 
body,  or  may  be  eliminated  with  difficulty  or  in  such  a 
concentrated  form  as  to  injure  tissues,  particularly 
those  of  the  excretory  organs,  —  the  kidneys. 

Again,  the  chemical  processes  of  digestion  require  a 
fluid  medium  for  action.  It  is  obvious  that  beefsteak 
or  dry  bread  cannot  go  through  the  intestinal  wall  as 
dry  powder  and  so  absorbed  by  the  blood.  Absorption 
takes  place  much  more  readily  if  there  is  a  reasonable 
amount  of  fluid  present.  There  has  always  been  a 


28 

superstition  that  water  or  fluid  drinking  with  the  meals 
was  harmful  to  health.  Experiments  have  shown  that 
copious  water  drinking  (one  to  two  quarts)  with  each 
meal  is  attended  by  no  harmful,  but  with  some  bene- 
ficial, results.  Experience  has  shown  that  limiting 
the  fluid  intake  often  causes  a  reduction  in  weight, 
which  merely  means  that  the  bodily  processes  are 
fed  by  the  tissues  of  the  body,  rather  than  by  the 
ingested  food.  I 

The  importance  of  water  cannot  be  overestimated, 
and  every  one  should  take  fluid  in  abundance.  Since 
the  requirements  vary,  depending  on  such  factors  as 
perspiration  and  the  like,  it  is  wise  roughly  to  regulate 
the  intake  by  controlling  the  output  at  approximately 
three  pints  of  urine  a  day.  The  form  in  which  water  is 
taken,  i.e.  in  foods  with  a  high  content  of  water,  in  fluid 
foods,  or  drinks,  makes  no  difference  to  the  bodily 
economy  so  far  as  water  itself  is  concerned.  It  is 
understandable,  however,  that  the  vehicle  carrying 
the  water  may  be  harmful  either  chemically  or  physi- 
cally. For  example,  water  with  caffein  (coffee),  water 
with  alkaline  salts  or  very  hot  or  very  cold  water  (ice- 
water)  may  injure  the  organism  through  the  extraneous 
characteristics  of  the  water.  The  injurious  effects  of 
excessive  ice-water  drinking  are  often  erroneously 
attributed  to  the  water  rather  than  to  the  temperature, 
just  as  the  beneficial  effects  of  water  drinking  at  a 
famous  health  spa  are  usually  erroneously  attributed 
to  some  mysterious  constituent  of  the  water  or  to  the 
temperature  of  the  water,  or  to  the  climate  rather  than 
to  the  simple  fact  of  water  drinking. 

Mineral  Matter.  Another  necessary  element  in 
nutrition  is  the  mineral  matter  which  contains  such 
elements  as  calcium,  potassium,  phosphorus,  sulphur, 
iron,  and  ordinary  salt.  These  salts  are  necessary 
for  the  various  structures  of  the  body,  but  we  need 


FOOD  29 

give  them  little  thought  in  arranging  our  diet,  as  a 
sufficient  supply  is  found  in  most  foods.  Ordinary 
salt  is  the  only  mineral  which  we  add  to  our  food, 
and  it  is  usually  not  even  necessary  to  do  this,  par- 
ticularly if  we  eat  animal  food.  We  get  sufficient 
supplies  in  milk  and  other  animal  foods,  but  we  must 
take  it  in  some  way,  for  upon  its  presence  depends 
the  osmotic  pressure  which  produces  many  of  the 
bodily  processes. 

Food  Values.  Only  the  substances  which  are  used 
to  build  up  tissue  and  supply  heat  are  usually  considered 
as  our  real  foods.  We  can  check  up  the  tissue-building 
effect  of  food  by  weighing  our  bodies  at  intervals.  But 
measuring  the  amount  of  heat  is  difficult.  It  is  suf- 
ficient to  say  that  it  has  been  done  "  and  very  carefully 
done  "  by  the  use  of  calorimeters.  Pettenkoffer,  Voit, 
and  others  carried  out  a  series  of  experiments  for  meas- 
uring the  amount  of  water,  air,  and  food  taken  in  and 
the  carbon  dioxide  passed  out;  examined  the^ urine; 
registered  every  motion  of  the  body,  and  analyzed 
the  results  which  they  obtained.  Thus  they  found 
that  all  foods  can  be  brought  down  to  the  basis  of  the 
large  calorie  which  is  the  foundation  of  all  the  energy 
of  food  value.  This  calorie  represents  the  amount  of 
heat  necessary  to  raise  the  temperature  of  one  kilogram 
of  water  one  degree  Centigrade,  or  one  pound  of  water 
four  degrees  Fahrenheit. 

Foods  are  generally  divided  into  three  classes,  but 
more  correctly  there  should  be  four,  —  protein,  carbo- 
hydrates, fat,  and  alcohol.  Alcohol  is  usually  omitted, 
but  we  have  to  admit  that  alcohol,  at  least  to  a  certain 
amount,  is  a  food,  for,  up  to  a  certain  point,  it  has  a  very 
definite  caloric  value. 

The  following  table,  prepared  by  Rubner,  gives  the 
caloric  value  of  the  four  kinds  of  foods  or  foodstuffs,  as 
they  should  be  called : 


30  HEALTH  AND  DISEASE 

1  gram  protein 4.1  calories 

1  gram  fat 9.5  calories 

1  gram  carbohydrates 4.1  calories 

1  gram  alcohol 7.0  calories 

From  this  table  it  will  be  seen  that  weight  for  weight 
fat  is  over  twice  as  valuable  as  either  protein  or 
carbohydrates.  The  problem,  however,  is  not  merely 
a  question  of  calories. 

Proteins.  The  proteins  include  all  nitrogenous 
foods  whether  of  animal  or  vegetable  origin,  except  the 
nitrogenous  fats.  As  nitrogen  is  the  basis  of  the 
muscle  and  tissue  throughout  the  body,  proteins  are  the 
tissue-building  foodstuffs.  The  proteins  include  such 
substances  as  the  lean  of  meat,  the  white  of  the  egg,  the 
lean  part  of  fish,  the  casein  and  albumen  of  milk,  wheat 
gluten,  and  parts  of  vegetables.  It  is  well  to  remember 
that  the  vegetables  which  contain  protein  form  tissue, 
as  well  as  the  animal  products.  The  animals  which 
serve  as  beef  are  exclusively  herbivorous.  These  ani- 
mals make  the  beef  or  the  meat  proteins  from  the  pro- 
tein of  the  vegetable  kingdom,  usually  grass,  hay,  and 
grain.  The  human  animal,  not  being  exclusively  her- 
bivorous, cannot  utilize  as  food  the  things  which  the 
beef  animals  do,  but  he  can  utilize  the  proteins  of  the 
vegetable  kingdom  just  as  the  beef  creatures,  and  can 
form  human  tissue  on  it.  Consequently  it  is  apparent 
that  the  vegetarian  may  not  differ  greatly  from  the  meat 
eater  in  the  -foodstuffs  which  he  consumes.  The 
vegetarian  goes  back  to  the  original  supply  for  his  pro- 
tein, while  the  meat  eater  takes  his  protein  slightly 
modified.  But  there  is  doubtless  some  qualitative 
difference  between  the  meat  and  vegetable  protein, 
although  it  cannot  be  expressed  by  a  chemical  formula. 
So  it  is  probably  advisable  for  us  to  get  some  part  of 
our  tissue-building  material  by  the  use  of  meat  protein. 
The  proteins,  in  addition  to  making  tissue,  may  give 


FOOD  31 

energy  to  the  body  when  the  supplies  of  carbohydrates 
and  fats  are  insufficient,  but  in  general  the  proteins 
are  only  tissue-builders.  The  use  of  proteins  to  fur- 
nish fuels  is  decidedly  poor  economy. 

Carbohydrates.  The  carbohydrates  include  the 
sugars,  gums,  and  cellulose,  and  form  the  principal 
constituents  of  all  kinds  of  plants.  Bread,  cereals, 
sugar,  and  the  vegetables  are  the  staple  carbohydrate 
foods.  Although  the  carbohydrates  are  derived  chiefly 
from  the  vegetable  kingdom,  they  are  also  present  in 
small  quantities  in  meat,  fish,  and  milk.  Cellulose  or 
vegetable  fiber  is  the  principal  constituent  of  grasses, 
green  vegetables,  and  fruits.  Unlike  the  herbivorous 
animals,  man  is  unable  to  utilize  cellulose  as  food  and 
it  has  no  food  value  in  human  dietary  tables. 

Fats.  The  fats  include  both  vegetable  and  animal 
fats,  such  as  those  of  milk,  butter,  olive  oil,  corn  oil, 
lard,  meat  fat,  and  certain  other  unimportant  elements. 
Vegetable  and  animal  fat  have  the  same  chemical 
formula  and  can  be  used  interchangeably  in  the  human 
body.  The  rather  despised  nut  has  a  large  food  value, 
for  it  is  rich  in  fat.  Neither  the  fats  nor  the  carbo- 
hydrates form  real  tissue,  but  when  they  are  taken  in 
excess  the  surplus  may  be  stored  up  as  adipose  or  fat 
tissue.  Such  tissue  is  hardly  a  body  tissue,  but  is  to 
be  regarded  as  stored  up  fuel.  Both  the  fats  and  the 
carbohydrates  spare  the  protein  elements  the  necessity 
of  producing  energy,  for  they  are  the  energy-producing 
part  of  our  diet  and  so,  indirectly,  serve  as  tissue- 
builders. 

Animal  Foods.  The  value  of  the  different  articles 
of  our  diet  in  nutrition  is  of  importance  in  arranging  our 
meals,  and  is  a  subject  where  recent  investigations 
have  changed  many  of  our  preconceived  ideas.  The 
animal  foods  naturally  come  first  in  consideration, 
as  these  products,  through  custom  and  tradition,  play 


32  HEALTH  AND  DISEASE 

so  great  a  part  in  our  diet.  In  meats  we  have  a  food 
which  is  high  in  protein,  from  fifty-one  to  eighty-nine 
per  cent,  a  varying  amount  of  fat,  from  five  to  forty-five 
per  cent,  and  practically  no  carbohydrate.  Contrary 
to  general  belief  there  is  little  difference  between  the 
food  values  of  red  and  white  meat.  The  difference  is 
only  in  the  presence  of  the  extractives  which  have  no 
positive  food  value.  The  average  food  value  of  meat 
runs  from  1,000  to  1,200  calories  per  pound. 

Fish  are  from  six  to  twenty-five  per  cent  protein,  a 
variable  amount  of  fat,  and  practically  no  carbohy- 
drates. Shell-fish  have  less  fat  and  a  low  food  value 
in  the  way  of  nourishment,  about  100  calories  per  pound. 
The  caloric  value  of  fish  runs  from  300  to  1,000  calories 
per  pound.  Salmon  is  of  high  value,  while  caviar  is  the 
highest  of  all. 

Eggs  have  been  overestimated  as  food,  and  they  are 
not,  contrary  to  general  belief,  a  highly  concentrated 
food.  The  white  of  the  egg  is  almost  pure  protein  and 
the  yoke  fat.  Thus  we  have  from  eleven  to  twelve 
per  cent  of  the  food  value  of  an  egg  in  protein,  and  from 
nine  to  ten  per  cent  fat.  The  total  food  value  is  about 
720  calories  to  the  pound. 

Milk,  as  well,  has  been  overestimated  in  the  popular 
mind,  and  a  glass  of  milk  is  by  no  means  a  square  meal. 
A  pound  of  milk  has  a  caloric  value  of  only  325,  which 
makes  a  glass  yield  about  160  calories.  The  importance 
of  milk  as  a  food  lies  in  the  proportions  of  fats,  carbo- 
hydrates, and  protein.  About  eighty-eight  per  cent 
of  milk  is  water,  four  per  cent  fat,  3.6  per  cent  protein, 
and  4.5  per  cent  carbohydrates.  The  child  needs  a  food 
with  a  considerable  amount  of  protein  and  thus  milk 
serves  him  well  as  a  food.  The  carbohydrates  of  milk 
are  in  the  form  of  milk  sugar,  or  lactose,  which  is  similar 
to  glucose.  The  essential  difference  between  human 
and  cow's  milk  lies  in  the  proportion  of  the  foodstuffs. 


FOOD  33 

Pure  milk  should  contain  twelve  per  cent  of  solids,  and, 
if  it  does  not,  it  is  due  to  the  fact  that  the  product  has 
been  adulterated.  The  favorite  way  of  adulterating 
milk  is  by  removing  the  fat  as  cream  and  adding  water 
and  sugar.  This  procedure  not  only  reduces  the  food 
value,  but  also  destroys  the  balance  of  the  foodstuffs. 

Butter,  cream,  cheese,  and  whey,  all  products  of  milk, 
play  a  considerable  part  in  the  average  diet.  Whey 
is  fat-free  milk.  Cream  has  about  twenty  per  cent  of 
fat.  Cheese  has  thirty  per  cent  of  fat,  thirty  per  cent 
of  protein,  and  the  rest  water.  Thus  it  is  obvious  that 
cheese  has  a  high  food  value,  a  fact  which  has  been 
greatly  underestimated  in  this  country. 

Vegetable  Foods.  Among  the  vegetable  foods, 
sugars  and  syrups  are  of  the  highest  food  value  as  they 
are  assimilated  by  the  body  with  but  little  change. 
The  fuel  value  of  sugar  is  practically  one  hundred  per 
cent.  Thus  candy  and  sweet  desserts,  which  are 
largely  sugar,  have  a  high  food  value. 

The  cereals  and  grains  furnish  us  with  most  of  our 
carbohydrates  and  considerable  protein.  Sixty-five 
to  eighty  per  cent  of  grains  are  carbohydrates  and 
from  six  to  twelve  per  cent  proteins.  It  is  obvious, 
therefore,  that  one  can  live  on  a  diet  of  bread  and 
butter,  for  such  a  diet  contains  all  the  food  elements. 
If  to  these  we  add  cheese,  we  get  a  balanced  diet. 

The  legumes,  peas  and  beans,  are  a  valuable  food,  for 
the  balance  between  the  carbohydrates  and  the  protein 
is  good.  The  protein  ranges  from  five  to  thirteen  per 
cent,  and  the  carbohydrates  from  thirteen  to  thirty 
per  cent.  In  a  dried  form  peas  and  beans  are  a  moder- 
ately concentrated  food  and  are  of  a  high  caloric  value. 

The  tubers  and  roots,  such  as  potatoes,  beets,  turnips, 
parsnips,  and  carrots,  contain  slightly  over  ten  per  cent 
of  carbohydrates,  but  no  protein  or  fat.  The  propor- 
tion of  water  content  is  high. 


34  HEALTH  AND  DISEASE 

Green  Vegetables  have  a  low  food  value,  only  from 
100  to  175  calories  per  pound.  Generally  they  are 
under  five  per  cent  of  carbohydrates,  with  little  or  no 
fat  or  protein,  and  much  cellulose  which  is  not  absorbed 
by  the  human  metabolism.  Cellulose,  however,  is  a 
desirable  constituent  of  diet,  as  the  digestive  system 
requires  considerable  bulk  on  which  to  work.  For  this 
reason  an  amount  of  green  vegetables  is  advisable  in 
the  dietary  for  the  sole  purpose  of  keeping  the  digestive 
tract  in  good  working  order.  These  green  vegetables, 
such  as  celery,  cabbage,  asparagus,  cucumbers,  cauli- 
flower, and  onions,  are  used  in  the  treatment  of  obesity 
by  filling  the  stomach  with  material  of  low  food  value, 
which  cannot  produce  tissue. 

Fruits  contain  cellulose,  water,  and  sugar,  although 
the  amount  of  carbohydrates  is  small,  from  five  to  ten 
per  cent.  Sweet  fruits,  like  cherries,  plums,  and 
sweet  oranges,  contain  more  carbohydrates.  The  food 
value  of  berries  is  very  low. 

Nuts  are  composed  of  from  forty  to  fifty  per  cent  of 
fatr  and  from  six  to  ten  per  cent  of  protein.  Thus  their 
food  value  is  high,  and,  as  their  cost  is  usually  low,  they 
make  a  comparatively  inexpensive  food. 

Alcohol.  Alcohol  is  definitely  a  food,  because  it  can 
be  burnt,  but,  on  the  other  hand,  only  a  small  amount 
can  be  used  in  the  body,  about  two  ounces  in  twenty- 
four  hours.  Any  excess  of  this  acts  as  a  poison.  Alco- 
hol goes  only  to  produce  heat,  and  cannot  in  any  way 
produce  tissue.  Whatever  claims  may  be  made  for 
alcohol  as  a  food,  the  fact  remains  that  in  this  regard 
it  is  nearly  negligible. 

Some  of  the  alcoholic  drinks,  the  malt  liquors,  for 
instance,  contain  some  nourishment  in  the  form  of 
carbohydrates,  but,  in  general,  these  drinks  depend  on 
the  amount  of  alcohol  for  any  food  value  as  well  as  for 
their  poisonous  effects.  Beer  and  ales  contain  from 


FOOD  35 

two  to  eight  per  cent  of  alcohol;  wines  from  two  to 
fifteen  per  cent,  the  amount  depending  on  the  extent 
of  the  fermentation  of  the  grapes ;  and  the  distilled 
liquors,  whiskey,  brandy,  and  gin,  as  well  as  the  liqueurs, 
from  forty  to  sixty  per  cent  of  alcohol. 

Condiments.  The  condiments  are  not  foods,  but 
simply  add  to  the  flavor.  Certain  foods  may  need  salt, 
but  we  probably  get  a  sufficient  supply  without  adding 
this.  Pepper,  mustard,  vinegar,  and  the  like  have 
absolutely  no  food  value.  When  they  are  combined 
into  salad  dressings,  there  is  usually  a  considerable  food 
value,  as  they  are  mixed  with  olive  oil.  The  oil  gives 
salads  the  only  food  value  which  they  may  possess. 

Beverages.  The  beverages  of  the  dietary  include 
coffee,  cocoa,  tea,  and  chocolate.  Of  these  tea  and 
coffee  are  the  most  alike  in  composition.  They  contain 
no  food  value  in  themselves,  but  depend  for  their 
action  on  certain  stimulating  qualities.  The  most 
important  element  is  caffeine,  and  the  amount  in  the 
average  cup  of  tea  and  coffee  is  about  the  same.  On 
the  other  hand,  the  way  in  which  we  take  coffee  and  tea, 
usually  with  milk  or  cream  and  sugar,  makes  the  drink 
of  some  slight  food  value,  for,  of  course,  the  food  value 
of  milk  and  sugar  is  high.  Preparations  of  coffee  which 
do  not  contain  caffeine  have  come  into  the  market  ex- 
tensively of  late  years,  and  the  advisability  of  their  use 
depends  chiefly  on  the  matter  of  taste.  The  stimulation 
of  caffeine,  in  moderate  amounts,  is  not  harmful.  In 
large  amounts,  as  when  taken  in  black  coffee  or  tea, 
caffeine  may  make  a  person  nervous  and  irritable,  and 
possibly  keep  him  awake  at  night.  It  is  true  that  an 
excess  of  these  beverages  may  make  the  user  nervous 
and,  perhaps,  make  him  feel  badly,  and  the  disturbance 
induced  by  an  excess  of  caffeine  may  be  the  underlying 
factor  of  disease,  but  such  an  excess  of  itself  causes  no 
organic  disease. 


36  HEALTH  AND  DISEASE 

Cocoa  contains  a  certain  amount  of  fat  and  an  active 
substance,  theobromin,  an  alkaloid  closely  allied  with 
caffeine.  Cocoa  is  usually  taken  with  milk  and  sugar, 
so  that  the  food  value  of  the  beverage  may  be  con- 
siderable. 

Chocolate  is  made  from  cocoa  and  contains  a  varying 
amount  of  starch  and  sugar,  depending  upon  the  par- 
ticular brand  of  the  product  which  is  used.  On  the 
whole,  the  nutritive  value  of  chocolate  is  not  large.  It 
contains  the  fat  of  cocoa  and  some  starch,  and,  in  some 
manufactured  forms,  considerable  sugar.  In  the  latter 
case  it  has,  of  course,  a  high  caloric  value. 

Availability  of  Food.  Merely  because  a  certain  food 
has  a  definite  food  value  expressed  in  calories,  it  does 
not  follow  that  the  ingestion  of  this  food  means  the 
complete  utilization  of  all  these  units.  An  unused 
portion  of  food  appears  in  the  excreta,  the  amount 
depending  to  a  considerable  extent  upon  the  efficiency 
of  the  individual's  digestive  system,  as  well  as  upon  the 
state  of  digestion  at  that  time.  Thus  in  order  to  know 
the  exact  value  of  any  product  as  a  food  it  is  desirable 
to  know  not  only  the  caloric  value,  but  also  the  amount 
which  is  lost  in  the  processes  of  digestion.  In  health, 
on  a  reasonable  diet  of  good  food,  little  food  escapes  in 
the  excreta.  It  is  estimated  that,  on  the  average,  ninety- 
one  per  cent  of  the  actual  food  value  in  a  balanced  diet 
is  utilized.  This  is  the  possible  upper  limit  and  pre- 
supposes perfect  digestive  processes.  Ninety-two  per 
cent  of  the  proteins,  ninety-five  per  cent  of  the  fats, 
ninety-seven  per  cent  of  the  carbohydrates,  —  those  of 
animal  origin  being  higher  than  those  of  vegetable  origin, 
—  and  ninety-eight  per  cent  of  alcohol  are  digested  and 
absorbed.  A  considerable  amount  of  the  nitrogen  of 
the  protein,  after  oxidation,  is  passed  off  through  the 
urine,  so  that  only  about  seventy  per  cent  of  the  protein 
actually  taken  in  is  available  for  the  work  of  the  body. 


FOOD  37 

While  the  availability  of  proteins  can  be  put  down  as 
seventy  per  cent  on  an  average,  these  figures  are  only 
true  with  an  average  balanced  diet  and  in  an  average 
individual  in  health.  In  disease  or  abnormal  conditions 
the  percentage  of  digestion  and  availability  may  be 
extremely  low.  Then,  too,  with  the  ingestion  of  an 
excess  of  one  food  factor  the  body  may  only  take  what 
it  requires,  a  fraction  of  the  amount  taken  in.  The 
power  of  assimilating  an  excess  of  the  food  factors  varies 
tremendously  with  different  individuals.  An  example 
of  this  is  seen  in  the  ingestion  of  a  large  amount  of  fat. 
In  most  persons  an  excess  of  fat  passes  through  the 
intestinal  tract  and  can  be  detected  readily  in  the 
feces.  The  excess  of  fat  has  only  acted  somewhat  as  a 
laxative,  not  as  a  food.  Thus  it  is  not  the  swallowing 
of  a  certain  amount  of  calories,  but  the  assimilation  of 
those  calories  that  determines  the  value  of  a  given  diet 
to  the  individual.  In  discussing  food  and  food  values 
the  food  itself  is  referred  to  and  not  the  available 
calories. 

Amount  of  Food.  The  amount  of  food  which  each 
individual  requires  depends  upon  many  factors.  The 
average  man  in  health,  theoretically,  demands  forty 
calories  of  food  per  kilogram  of  weight  every  twenty- 
four  hours,  but  in  actual  experience  we  find  that  some 
people  require  sixty  calories  and  others  only  half  of 
that.  Then  the  extent  of  the  body  surface  is  another 
determining  factor.  Children,  who  have  a  relatively 
large  body  surface  in  proportion  to  their  weight,  require 
more  calories  per  kilogram.  Thin  people,  because  of 
the  relatively  larger  body  surface,  also  require  more 
food  for  body  weight  than  many  of  greater  weight. 
On  the  other  hand  old  people  require  much  less  food 
than  a  growing  child  or  a  man  at  hard  work.  Old 
people,  unless  very  fat,  often  get  along  on  from  twenty- 
six  to  thirty-six  calories  of  food  per  kilogram  of  weight. 

138139 


38  HEALTH  AND  DISEASE 

It  naturally  follows  that  a  man  at  hard  work  needs 
more  food,  i.e.  more  energy,  than  a  man  who  does  little 
work.  Women  require  only  about  four-fifths  as  much 
food  as  a  man,  due  largely  to  smaller  size,  a  high  per- 
centage of  body  fat,  and  a  less  strenuous  existence. 

Climate  and  season  exert  some  influence  on  the 
amount  of  food  taken  in  and  used  up,  but  the  use  of 
clothing  reduces  the  influence  of  these  factors.  To 
some  extent  cold  weather  requires  more  heat-making 
materials  in  the  dietary. 

The  most  important  factor  in  influencing  the  amount 
of  food  required  is  the  amount  of  muscular  work  done. 
But  physical  exercise,  in  the  usual  sense,  is  only  a  small 
amount  of  the  work  for  which  the  body  has  to  supply 
energy.  About  eighty  calories  out  of  every  hundred 
are  used  up  by  the  body  as  heat  and  internal  work. 
Sitting  about,  writing,  reading,  and  the  like  use  up  a 
considerable  amount  of  energy.  It  is  generally  believed 
that  a  man  at  moderately  hard  work  requires  about 
3,000  calories  per  twenty-four  hours,  which  he  can  get, 
of  course,  only  from  his  food.  It  is  also  generally 
accepted  that  brain  work  makes  no  great  demand  upon 
the  food  supply. 

The  accepted  standards  of  the  amount  of  food 
required  are  about  as  follows : 

Man  without  muscular  work 2,450  calories 

Man  with  light  muscular  work  (sedentary)      .     .  2,700  calories 

Man  with  light  to  moderate  muscular  work     .     .  3,050  calories 

Man  with  moderate  muscular  work 3,400  calories 

Man  with  very  hard  muscular  work 5,500  calories 

Excess  and  Deficit  in  Food  Amounts.  As  the 
result  of  experiments  it  has  been  found  that  a  healthy 
man  can  live  and  maintain  his  health  and  weight  on 
fewer  calories  than  are  given  in  the  tables.  Such  experi- 
ments need  in  no  way  confuse  us.  In  the  first  place, 


.FOOD  39 

everyone  has  his  individual  variations,  and  in  the  second 
we  must  consider  the  adaptability  of  Nature.  Nature 
accommodates  herself  easily  in  health,  and  it  is  remark- 
able on  how  little  food  we  can  exist.  Yet  living  in 
health  on  a  scanty  diet  misses  two  important  considera- 
tions :  the  margin  of  safety  against  the  fluctuating 
demands  of  the  body  created  by  unusual  increased 
activity  or  disease,  and  the  habit  of  the  individual  or 
the  race.  Certain  individuals  and  certain  races  habitu- 
ally use  less  food  than  others.  As  there  are  other 
habits,  so  there  is  a  food  habit,  and  accommodating 
Nature  makes  the  best  of  it.  Once  a  habit  is  fixed,  it 
means  the  confusion  of  the  whole  machinery  of  the  body, 
if  that  habit  is  changed.  This  is  as  true  of  bad  habits 
of  eating  as  of  good  habits.  The  acquisition  of  a  habit 
of  eating  a  reasonable  amount  of  food  should  be  acquired 
as  early  as  possible. 

Fundamentally  the  human  animal  is  like  any  other 
animal.  A  plump  animal  is  synonymous  with  a  well-fed 
animal  but  there  is  wide  individual  variation  in  size, 
even  among  brutes  of  the  same  litter.  In  the  human 
animal  the  individual  variation  plays  a  large  part  in 
the  question  of  size  and  the  amount  of  food  which  he 
requires.  Roughly  speaking  the  fat  man  has  three 
characteristics :  he  eats  a  targe  amount  of  food ;  his 
bodily  machine  is  so  regulated  that  the  food  which  he 
takes  is  absorbed  —  that  is  he  has  a  high  availability  of 
food;  and  he  burns  up  little  food  in  muscular  work. 
Any  one  of  these  three  factors  may  be  predominant. 
Usually  the  fat  man,  however,  eats  more,  absorbs  more 
/of  what  he  eats,  and  is  less  active  than  the  thin  man. 
Lethargy  and  obesity  are  common  associates.  But, 
contrary  to  the  general  opinion,  the  lethargy  and  in- 
activity, which  burn  up  less  food,  are  the  causative 
factors  of  the  obesity,  rather  than  that  the  obesity  is  the 
cause  of  the  lethargy  and  inactivity. 


40  HEALTH  AND  DISEASE 

On  the  other  hand,  the  lean  individual  tends  to  eat 
less,  to  absorb  less  of  what  he  eats,  and  to  be  more  active 
than  the  obese  person.  We  are  all  familiar,  however, 
with  the  lean  man  who  is  a  large  eater.  Of  course,  in 
some  instances,  leanness  is  merely  one  evidence  of 
disease.  Yet  there  are  many  lean  persons  who  cannot 
adjust  their  digesting  and  absorbing  mechanism  so  that 
they  can  absorb  and  get  the  benefit  from  more  than  a 
fixed  amount  of  food  value.  Their  machines  seem  to 
be  set  permanently  at  a  certain  level  and  anything  in 
excess  is  waste.  Often  a  lean  person  is  thin  on  account 
of  an  excessive  activity  which  is  manifest  throughout 
his  waking  hours.  It  seems  to  be  impossible,  for  ex- 
ample, for  such  a  person  even  to  sit  quietly  reading  for 
any  length  of  time.  Any  task  is  performed  with  an 
extraordinary  amount  of  unnecessary  motions.  Ex- 
cessive activity  is  the  reason  why  children  froni  eight 
to  fourteen  years  of  age  tend  to  be  thin.  At  middle^life 
most  people  tend  to  put  on  weight.  Here  the  determin- 
ing factor  is  usually  activity.  They  have  acquired  a 
habit  of  taking  a  certain  amount  of  food,  and  with  the 
lessened  activity  natural  at  this  time  of  life  the  usual 
outcome  is  an  increase  in  weight.  Transportation  by 
trains,  electric  cars,  elevators,  and  automobiles,  com- 
munication by  telephone  and  by  post,  labor-saving  de- 
vices and  other  conveniences  of  modern  life,  all  con- 
spire with  the  variety  and  greater  appetizing  qualities 
of  the  diet  to  induce  obesity.  The  incidental  activities 
of  everyday  life  are  decreasing  and  we  tend  to  eat 
more  than  we  use  up. 

It  is  probably  wise  to  make  our  mistakes  on  the  side 
of  a  slight  excess  of  food  and  of  a  slight  amount  of  fat 
tissue.  A  slight  amount  of  fat  represents  stored  fuel 
of  heat  and  energy.  Furthermore,  we  find  in  the  story 
of  the  cure  of  consumption  and,  indeed,  in  its  preven- 
tion, an  illuminating  example  of  the  importance  of  an 


FOOD  41 

ample  diet  (in  conjunction  with  other  measures,  to 
be  sure)  in  resisting  and  conquering  disease.  On  the 
other  hand,  while  fatty  degeneration  of  the  heart  as  a 
dreadful  complication  of  obesity  has  been  discarded  by 
the  medical  profession,  it  is  true  that  an  excess  of  weight, 
since  fat  is  not  a  structural  tissue,  only  stored  heat, 
merely  means  an  unnecessary  burden.  It  must  be 
carried  about,  supplied  with  blood,  and  entails  increased 
work  for  all  the  organs.  It  is  as  if  a  man  in  a  land  of 
plenty  carried  constantly  many  pounds  of  provisions 
which  he  never  would  use. 

Number  of  Meals  a  Day.  Custom  in  this  country 
has  established  the  three-meal-a-day  habit.  This  cus- 
tom conforms  to  the  conditions  of  our  industrial  life. 
Many  people,  however,  deviate  from  this  custom  by 
eating  from  one  to  six  meals  a  day.  Ordinarily  it  is 
difficult  to  consume  and  take  care  of  a  day's  ration 
in  one  meal.  Certain  individuals  require  several  meals 
in  order  to  enable  their  organs  to  extract  food  values 
from  the  ingested  food.  The  important  consideration  is 
habit.  Irregular  meals  will  find  the  digestive  functions 
prepared  at  a  certain  time  to  receive  a  certain  amount  of 
food.  If  the  food  is  not  forthcoming,  Nature's  remon- 
strances are  usually  made  evident  by  a  variety  of  sen- 
sations, often  hunger,  sometimes  faintness,  headache, 
lassitude,  and  the  like.  Likewise,  Nature  resents  the 
insult  of  a  large  meal  at  an  unaccustomed  hour.  ,  It  is 
not  too  much  to  say  that  food  should  not  be  taken 
continuously.  Probably  the  two-meal  habit  with  a 
wide  interval  for  rest  of  the  digestive  functions  has 
much  to  recommend  it.  For  the  average  individual 
the  chief  concern  should  be  that  his  meals,  two  or  six 
in  number,  should  be  reasonably  regular.  Undoubtedly 
a  goodly  share  of  the  usual  Monday  depression  is  due 
to  the  custom  of  departing,  on  Sunday,  from  regular 
habits  of  eating.  It  also  follows  that  the  decision  of 


42  HEALTH  AND  DISEASE 

when  the  hearty  meal  should  be  eaten  depends  largely 
on  the  question  of  habit.  It  is  well  known  that  a 
hearty  meal  induces  a  soporific  tendency  which  is  merely 
an  indication  of  the  concentration  of  the  bodily  energy 
in  the  digestive  tract.  Consequently  the  hearty  meal 
should,  by  preference,  not  be  habitually  taken  with  a 
prospect  of  bodily  activity  immediately  afterwards. 

Balanced  Diet.  It  would  seem  fairly  simple  to  ar- 
range a  diet  on  the  basis  of  amounts,  as  one  can  consult 
tables  of  food  values  and  select  sufficient  calories  to 
supply  the  necessary  amount  of  food.  But  it  is  neces- 
sary to  know  more  than  the  total  amount  of  calories. 
The  diet  must  also  be  well  balanced  between  the  food 
factors.  Unless  the  diet  is  reasonably  balanced,  we 
have  no  right  to  assume  the  average  assimilation,  and, 
in  fact,  there  is  a  great  deal  of  evidence  to  the  contary. 
We  all  require  a  balanced  diet  to  secure  the  most  effec- 
tive nutrition.  As  we  have  seen,  the  proteins  are  the 
tissue-builders,  while  the  carbohydrates  and  fats  supply 
the  fuel.  While  a  man  could  live  on  a  diet  of  pure  pro- 
tein, he  could  not  survive  on  a  diet  consisting  only  of  fats 
and  carbohydrates.  The  main  question,  therefore,  is 
the  amount  of  protein  a  diet  should  contain. 

A  diet  exclusively  of  proteins  will  support  life,  but 
the  individual  subsisting  on  such  a  ration  will  suffer 
from  a  variety  of  intestinal  and  other  derangements 
which  are  merely  Nature's  protest  against  such  an  ill- 
advised  proceeding.  An  excessive  diet  of  protein  is  often 
accompanied  by  immediate  disorders  of  a  varying  kind, 
but  there  is  also  considerable  evidence  that  such  a  diet 
eventually  causes  damage  to  the  kidneys  and  to  the  other 
organs.  In  some  mysterious  fashion  certain  forms  of 
rheumatism  and  neuralgia  are  associated  with,  even  if 
not  caused  by,  an  excess  of  protein  food.  Scientists  are 
not  so  certain  as  the  laity  about  the  direct  relation 
between  protein,  especially  meat,  and  gout.  It  is 


FOOD  43 

certain  that  the  disturbance  in  gout  centers  about  a 
protein  derivative,  uric  acid,  which  is  found  in  large 
amounts  in  such  protein  foods  as  sweetbreads,  liver,  and 
kidneys,  and  to  a  less,  but  still  considerable,  extent 
in  ordinary  meat.  In  families  which  suffer  from  gout 
there  is  often  a  history  of  excessive  meat  eating.  A 
constant  and  stern  adherence  to  a  reasonable  intake 
of  food  with  a  moderate  amount  of  protein,  often  re- 
lieves the  gouty  sufferer  from  what  seems  to  be  the 
belated  penalty  of  the  earlier  indiscretions,  either  of 
himself  or  of  his  ancestors,  in  excessive  protein  con- 
sumption. 

Experiments  have  also  indicated  that  one  result  of  the 
consumption  of  an  excess  of  protein  is  an  increase  in  the 
bodily  heat.  This  increase  is  marked  with  protein 
consumption,  less  marked  with  fat  consumption,  and  is 
hardly  noticeable  after  the  intake  of  even  an  excess 
of  carbohydrates.  This  again  illustrates  how  nearly 
practice  coincides  with  science ;  namely,  that  in  the  heat 
of  the  summer  or  of  the  Tropics  one  is  probably  more 
comfortable  if  the  amount  of  protein  intake  is  not 
excessive.  The  fat  intake  also  should  not  be  excessive, 
but  carbohydrates  may  be  taken  in  abundance. 

A  diet  with  too  little  protein  causes  an  inability  to 
repair  and  replace  bodily  tissue,  a  loss  of  strength, 
anemia,  and  a  diminished  resistance  to  disease. 

Carbohydrates  alone  cannot  support  life,  and  if  they 
are  taken  in  excess  of  the  requirements  of  the  body  the 
excess  will  be  stored  up  as  fat.  Such  an  excess  of 
carbohydrates  may  give  warning  of  the  condition  by 
digestive  disturbances.  While  we  cannot  as  yet  di- 
rectly associate  diabetes  with  an  excessive  consump- 
tion of  carbohydrates,  a  possible  relation  is  evident. 
A  diet  with  insufficient  carbohydrates  tends  to  produce 
a  harmful  condition  of  body  associated  with  an  increased 
acidity  of  the  structures. 


44  HEALTH  AND  DISEASE 

A  diet  of  fat  alone  cannot  support  life.  An  excess 
of  fat  in  the  diet  promptly  appears  in  the  f eces  and  is 
wasted.  Many  people  cannot  take  in  and  absorb  more 
than  one  hundred  grams  of  fat  a  day  without  digestive 
disturbances.  Carbohydrates  and  fats,  since  they  do 
the  same  work,  can  be  used  interchangeably,  the  essen- 
tial difference  being  that  carbohydrates  can  be  assimi- 
lated in  almost  unlimited  amounts,  while  the  fats 
cannot.  A  further  and  very  practical  difference  is 
that  the  carbohydrates  are  derived  from  a  large  variety 
of  foodstuffs  which  can  be  served  in  many  palatable 
forms.  The  variety  of  fats  is  not  great  and  foods  of 
marked  fatty  content,  as  butter,  cream,  and  the  oils, 
are  not  appetizing  to  many  people.  A  curious  nausea 
and  loss  of  appetite  often  follows  an  attempt  to  in- 
crease fats  in  the  diet  to  any  considerable  degree.  An 
insufficient  supply  of  fat,  while  theoretically  unde- 
sirable, can  be  compensated  for  by  an  increase  of 
the  carbohydrate  intake.  So  far  as  known,  the  ill 
effects  of  a  fat  deficit  in  the  diet  are  due  to  the  excess 
of  carbohydrates. 

Thus  it  is  obvious  that  the  balance  of  foodstuffs  in 
the  diet  is  an  important  factor  in  health  and  disease. 
According  to  the  best  figures  the  proportions  of  food- 
stuffs should  be  100  grams  of  protein,  150  grams  of  fat, 
and  350  grams  of  carbohydrates.  About  ten  per  cent 
of  the  food  values  of  a  diet  should  be  derived  from  pro- 
tein food,  and  at  least  half  of  this  protein  should  be  of 
vegetable  origin.  Experiments  have  shown  that  it  is 
possible  to  live  and  maintain  strength  on  thirty  grams 
of  protein  per  day,  so  that  it  is  probably  true  that  we,  as 
a  nation,  eat  too  much  meat.  A  proper  diet  should  have 
the  proper  proportions  of  foodstuffs  and  should  be 
slightly  in  excess  of  the  amount  required  to  repair  tissue 
and  furnish  energy,  so  that  there  may  be  a  reserve  of 
fuel  in  the  body. 


FOOD  45 

If  we  examine  roughly  the  combination  of  foods  that 
are  constantly  used,  we  find  a  reasonable  balance. 
Meat,  which  is  high  in  protein,  is  rarely  eaten  alone,  but 
in  combination  with  potatoes  and  other  vegetables, 
which  are  mostly  carbohydrates.  Bread  and  butter 
is  an  almost  universal  combination  and  it  provides  a 
balanced  ration.  The  Italians  add  cheese  —  fat  and 
protein  —  to  their  macaroni  —  carbohydrates.  Every- 
where there  is  a  universal  tendency  to  secure  a  balanced 
combination  of  food. 

Under  certain  conditions  of  hard  work  it  is  necessary 
to  increase  the  amount  of  food,  while  the  requirements  of 
a  sedentary  life  are  so  slight  that  the  food  should  be 
diminished.  Yet  the  general  proportion  of  the  food- 
stuffs should  be  maintained  roughly,  whether  the  body 
needs  1,500  or  9,000  calories.  The  old  superstition 
largely  prevails  that  active  and  particularly  athletic 
men  need  a  large  amount  of  protein.  It  is  true  that 
they  use  and  therefore  need  more  food  than  the  inactive 
person,  but  repeated  experiments  have  shown  that  their 
requirements  indicate  the  consumption  of  the  same 
percentage  of  proteins  as  the  inactive  person.  The 
athlete,  like  the  engine,  relies  on  fuel,  and  the  fuel  in  the 
case  of  the  athlete  is  carbohydrates  and  fats.  Con- 
sequently beef,  while  in  limited  amounts  it  is  the  basis 
of  the  formation  of  muscle,  in  excess  does  not  furnish  an 
excess  of  energy,  but  rather  handicaps  by  subjecting 
the  taker  to  the  penalties  of  an  excessive  protein  diet. 

Bulk  of  Food.  The  concentrated  food  tabloid, 
which  will  give  an  adequate  food  value  in  small  bulk, 
has  been  the  cause  of  much  wasted  effort.  In  point  of 
fact  it  is  highly  desirable  that  we  eat  bulky  foods  and 
avoid,  to  a  certain  extent  at  least,  the  concentrated 
foods.  Food  bulk  furnishes  the  stomach  and  the  twenty 
odd  feet  of  intestine  with  material  on  which  to  work. 
Bulk  increases  the  activity  of  the  bowels  and  helps 


46  HEALTH  AND  DISEASE 

to  relieve  that  much-underestimated  evil  peculiar  to 
civilization  —  constipation.  Many  foods,  such  as  cel- 
ery, spinach,  lettuce,  the  group  of  green  vegetables,  and 
the  various  fruits,  have  so  little  food  value  as  to  be 
almost  negligible,  and  yet  experience  shows  that  they 
are  of  great  value  in  furnishing  bulk.  Of  course,  one 
could  not  live  exclusively  on  such  substances,  but  they 
should  play  an  important  part  in  the  daily  ration.  In 
addition  to  their  value  for  bulk,  it  seems  probable  that 
they  may  contain  some  of  the  mysterious  and  important 
vitamins. 

Vitamins.  If  an  individual  takes  a  sufficient  number 
of  calories  of  clean  food  for  his  requirements  of  tissue 
growth  and  repair  and  for  his  energy,  and  these  calories 
are  properly  balanced  as  to  proteins,  carbohydrates,  and 
fats,  and  if  he  takes  sufficient  water  and  mineral  salts, 
can  we  guarantee  that  he  has  all  the  elements  necessary 
to  maintain  life  and  health?  Such  a  question  has  to 
be  answered  in  the  negative.  There  are  other  myste- 
rious substances  of  no  food  value  and  of  unknown  chemi- 
cal composition,  which,  in  our  present  state  of  igno- 
rance, we  call  vitamins.  How  many  there  are,  what 
they  are,  and  how  they  act,  we  do  not  know.  Bitter 
experience,  and  not  science,  first  acquainted  us  with  the 
disease  conditions  associated  with  a  lack  of  vitamins. 
The  best  known  of  such  diseases  is  scurvy.  When 
sailors  returned  from  a  long  cruise  on  a  sailing  vessel, 
it  was  occasionally  found  that  some  of  them  were  suf- 
fering from  a  peculiar  disease  called  scurvy.  This  dis- 
ease was  promptly  cured  by  the  addition  of  fresh  fruit 
to  the  diet.  Likewise,  bottle-fed  babies,  particularly 
if  the  milk  is  prepared  and  is  not  fresh,  occasionally 
suffer  from  the  same  disease.  A  little  orange  juice 
suffices  to  cause  a  prompt  and  complete  recovery. 
Under  these  conditions  the  calories  of  the  diet  are  usu- 
ally abundant,  but  there  is  a  lack  of  something  which 


FOOD  47 

the  body  requires  and  which  fresh  fruit  and  vegetables 
and  milk  will  supply. 

Beri-beri,  another  disease  condition  with  an  entirely 
different  symptomatology,  can  now  be  put  in  the  same 
category.  This  disease  has  been  described  in  the 
Orient  and  in  Labrador  and  is  seen  occasionally  all  over 
the  world.  It  is  most  commonly  associated  with  the 
large  use  of  polished  rice  and  the  exclusion  of  fresh  meat 
and  vegetables  from  the  diet.  The  disease  may  be 
prevented  and  cured  by  the  use  of  whole  rice.  The 
inference  is  that  there  is  in  the  covering  of  the  rice  a 
substance  of  no  caloric  value,  but  nevertheless  essential 
to  life.  This  disease  has  also  been  noted  in  people 
who  live  almost  exclusively  on  other  substances  which 
have  been  so  treated  in  manufacture  as  to  lose  the  outer 
covering  of  the  grains. 

Still  another  disease  of  still  different  symptomatology, 
apparently  caused  by  a  lack  of  vitamins,  is  pellagra. 
This  disease  was  long  associated  with  a  diet  almost 
exclusively  of  maize  or  corn  and  was  most  common  in 
Italy.  Cases  have  been  fairly  frequent  in  our  Southern 
States  and  occasionally  it  has  appeared  in  the  Northern 
States.  It  was  not  until  officers  of  the  U.  S.  Public 
Health  Service  were  able  to  reproduce  the  disease  by 
feeding  healthy  persons  on  a  restricted,  one-sided, 
mainly  carbohydrate  (cereal)  diet,  including  grain,  but 
excluding  meat,  that  we  had  a  clear  idea  of  the  causation 
of  pellagra.  This  experimental  diet  contained  3,000 
calories  a  day. 

It  seems  probable  that  we  shall  find  other  disease  con- 
ditions due,  not  to  a  lack  of  calories  and,  usually, 
not  a  lack  of  balance,  but  to  the  absence  of  these 
mysterious  vital  substances,  which  a  very  restricted 
diet  may  not  include.  Perhaps  rickets  in  children  is 
related  to  this  group  of  diseases.  We  are  only  at  the 
threshold  of  knowledge  of  these  conditions.  The 


48  HEALTH  AND  DISEASE 

startling  facts  concerning  the  relation  of  polished  rice 
to  beri-beri  have  aroused  apprehension  concerning  all 
the  highly  milled  cereals.  As  civilization  has  advanced 
the  highly  milled  products,  which  contain  less  of  the 
husk  and  more  of  the  kernel  and  thus  less  of  the  vita- 
mins, have  increased  in  use.  Then,  too,  experiments 
seem  to  indicate  that  the  alkali  which  is  found  in  baking 
soda  tends  to  destroy  the  vitamins  of  the  bread  and  thus 
still  further  diminish  the  already  low  vitamin  content 
of  the  bread  from  the  highly  milled  cereal.  This  may 
prove  to  be  a  problem  of  increasing  seriousness  since, 
particularly  among  the  poor,  there  has  been  a  marked 
falling  off  in  the  use  of  the  vitamin-rich  foods  ordi- 
narily used,  such  as  fresh  eggs,  fresh  milk,  meat,  fresh 
fruits,  and  vegetables.  However,  there  seems  tobe  little 
danger  unless  the  diet  is  almost  entirely  of  a  limited 
variety  of  vitamin-poor  foods,  and  it  requires  a  really 
extraordinarily  small  amount  of  these  mysterious  sub- 
stances to  insure  health.  It  is  encouraging  that  new 
sources  of  vitamins  are  being  brought  to  light,  such  as 
brewer's  yeast  which  is  very  rich  in  them.  But  these 
facts  need  serious  consideration  and  strongly  indicate 
that  it  is  always  wise  to  include  in  our  dietary  some 
fresh  foods,  milk,  eggs,  meats,  fruit,  and  vegetables. 
Perhaps  the  fundamental  lesson  is  that  foods  in  their 
fresh  natural  state  contain  certain  substances  which  are 
necessary  to  life  and  which,  consequently,  are  superior 
to  the  food  products  which  have  been  artificially  treated 
to  any  great  extent.  This  fact  is  not  yet  apparent  from 
chemical  analysis  or  from  the  caloric  value  of  food. 

Anaphylaxis,  or  Hypersensitiveness  to  a  Foreign 
Protein.  Recent  brilliant  investigations  have  thrown 
light  on  the  long-known  curious  phenomena  that  certain 
persons  are  poisoned  by  partaking  of  certain  foods. 
This  form  of  poisoning  may  manifest  itself  in  many 
ways.  Perhaps  the  most  common  manifestation  is  the 


FOOD  49 

rapid  appearance,  after  eating,  of  urticaria  or  hives, 
an  intensely  itching  variety  of  skin  eruption.  Often 
gastro-intestinal  disturbances  of  varying  intensity  are 
present.  There  may  even  be  asthmatic  attacks.  In 
brief,  there  is  the  picture  of  acute  poisoning,  varying 
from  a  trivial  attack  to  one  of  great  intensity.  This 
phenomenon  has  been  found  to  be  similar  to  the  mys- 
terious one  known  as  anaphylaxis. 

It  had  been  discovered  previously  that  some  animals 
can  be  poisoned  and  even  killed  by  the  double  injection 
of  a  foreign  protein.  The  first  injection  serves  to  make 
the  animal  sensitive  to  the  second  injection  of  the 
same  protein.  If  a  guinea  pig  is  inoculated  with  any 
foreign  protein  —  the  white  of  an  egg  or  the  protein 
from  a  horse  or  a  sheep  —  a  second  injection  of  the 
same  protein,  even  in  small  amounts,  will  usually  kill 
the  animal.  The  first  injection  is  quite  harmless  and 
the  second  injection,  if  of  any  other  protein  than  that 
given  before,  is  equally  harmless.  Other  discoveries 
have  followed  in  rapid  succession.  It  has  been  found 
that  it  is  not  necessary  for  the  protein  to  be  injected. 
It  can  act  when  inhaled,  and  hay  fever  is  already  a 
classical  example  of  this  form  of  anaphylaxis.  In  true 
hay  fever  a  person  is  somehow  sensitized  by  inhaling 
the  pollen  of  ragweed.  This  pollen  contains  a  relatively 
small  amount  of  protein,  but  the  phenomenon  is  ap- 
parently entirely  a  protein  characteristic.  Such  a  per- 
son is  poisoned  and  has  hay  fever  whenever  he  inhales 
ragweed  pollen. 

Other  people  are  similarly  affected  by  the  proteins  of 
other  grasses  and  weeds.  Then  still  others  are  affected 
by  horses,  dogs,  cats,  and  rabbits.  This  condition 
usually  takes  the  form  of  asthma  and  is  known  as  horse 
asthma,  dog  asthma,  and  so  on.  It  has  developed 
that  the  same  phenomenon  takes  place  in  certain  sus- 
ceptible people  when  the  foreign  protein  is  taken  in  the 


50  HEALTH  AND  DISEASE 

mouth.  It  is  true  that  the  action  of  the  substance  is 
most  certain  when  it  is  injected  and  least  so  when  taken 
in  by  mouth  and  thereby  subjected  to  the  action  of  other 
substances  as  well  as  to  the  digestive  juices.  Thus,  in 
many  cases,  it  has  been  found,  anaphylaxis  or  hyper- 
sensitiveness  is  the  cause  of  poisoning  by  berries,  fish, 
eggs,  almonds,  and  the  like.  Many  of  these  substances 
contain  so  little  protein  that  it  is  negligible  as  a  food,  yet 
it  is  the  protein  part  which  causes  the  poisoning.  This 
list  could  be  extended  to  include  many  foods.  A  strik- 
ing illustration  of  anaphylaxis  is  occasionally  seen  in  the 
weaning  of  infants.  Cow's  milk  poisons  certain  infants, 
yet  goat's  milk  will  not. 

Many  details  of  the  explanation  of  this  phenomenon 
of  anaphylaxis  are  still  lacking.  We  do  not  know  how 
the  individual  becomes  sensitized  in  the  first  place. 
We  know  that  a  general  tendency  to  anaphylaxis  seems 
to  run  in  certain  families.  Yet  this  sensitiveness  may 
take  the  form  of  hay  fever  in  one  member  of  the  family, 
horse  asthma  in  another,  almond  or  egg  poisoning  in  a 
third,  and  so  on.  Anaphylaxis  is  much  more  frequent 
in  early  life  and  the  tendency  is  often  outgrown.  The 
phenomenon  of  anaphylaxis  is  often  very  striking  even 
with  small  amounts  of  protein.  Clinical  tests  for  this 
condition  are  being  developed  which  consist  of  simply 
rubbing  the  food  in  question  upon  scratches  on  the 
arm.  If  there  is  hypersensitiveness,  a  swelling  appears 
about  the  scratch  with  a  certain  food,  which  is  not 
present  with  other  foods.  Investigations  for  the  relief 
of  this  condition  are  being  undertaken  and  indicate  that 
the  body  can  lose  its  abnormal  sensitiveness  to  these 
poisons  by  being  repeatedly  subjected  to  carefully 
graded  amounts  of  this  foreign  protein. 

In  general,  except  under  the  best  medical  supervision, 
it  is  wisest  to  avoid  most  carefully  the  foods  to  which 
we  are  hypersensitive.  This  phenomenon  of  anaphy- 


FOOD  51 

laxis  is  undoubtedly  a  large  factor  in  many  of  the 
digestive  upsets  which  recur  repeatedly  in  some  people, 
and  it  is  probably  a  more  important  factor  than  we,  in 
our  limited  knowledge,  now  realize. 

Influence  of  the  Emotions  on  the  Food  Problem. 
Many  of  the  lower  animals  live  and  maintain  their 
health  on  a  monotonous  diet,  and  some  human  beings 
are  able  to  do  the  same.  To  the  really  hungry  man 
food  is  food  and  his  appetite  requires  little  whetting  by 
pleasant  surroundings,  clean  table  linen,  appetizing 
sauces,  and  new  and  unexpected  combinations  of  food, 
and  the  like.  Yet  the  absence  of  these  things  and  even 
the  contact  with  food  which  is  essential  to  its  prepara- 
tion occasionally  suffices  to  make  eating  well  nigh  intol- 
erable to  a  sensitive  person.  Food  values  and  calories 
are  forgotten.  Nor  are  the  lower  animals  exempt  from 
these  sensations.  Under  such  circumstances  the  dis- 
tinction between  the  animal  and  the  artificial  machine 
becomes  clear. 

The  profound  influence  of  the  emotions  on  the 
digestive  apparatus  has  been  well  shown  by  the  experi- 
ments of  Dr.  Walter  B.  Cannon,  of  the  Harvard  Medical 
School.  By  means  of  the  X-ray  and  a  meal  containing 
an  impenetrable  substance  like  bismuth,  the  digestive 
system  of  a  cat  can  be  observed  to  manifest  remarkable 
and  sudden  changes  in  the  hitherto  placid  activity 
when  the  cat  becomes  enraged  at  a  dog. 

The  nausea  of  fear,  the  diarrhea,  the  sweating,  and 
the  frequent  urination  so  frequently  seen  at  times  of 
stress  and  excitement,  as  before  student  examinations 
and  athletic  contests,  are  common  evidences  of  the 
influence  of  the  emotions  on  bodily  functions.  Emo- 
tions, especially  in  certain  individuals,  have  the  power 
of  deranging  seriously  the  digestive  functions.  Fatigue, 
likewise,  is  an  important  factor  which  will  put  awry 
the  nice  mathematical  tabulation  of  food  values. 


52  HEALTH  AND  DISEASE 

Granted  that  these  considerations  play  only  a  small  r61e 
in  the  completely  healthy  person,  yet,  under  the  condi- 
tions of  our  so-called  civilization,  the  factors  of  emotion 
and  fatigue  must  be  considered  seriously.  Under  the 
influence  of  extreme  fatigue  or  grief,  a  person  may  grow 
thin  on  an  adequate  diet,  or  various  digestive  dis- 
turbances may  arise  which  are  attributed,  only  too 
often,  to  food  and  not  to  the  actual  causes,  the  emotions. 
A  worried  man  attributes  his  indigestion  not  to  his  worry 
but  to  his  beef,  notwithstanding  the  fact  that  he  has 
eaten  beef  for  many  years  without  experiencing  any 
difficulty. 

On  the  other  hand  we  see  and  we  constantly  make  use 
of  the  favorable  effect  of  pleasure  on  the  digestion. 
Pleasure  in  the  company,  the  serving  of  the  food,  the 
attractiveness  of  the  food  combinations  pave  the  way  to 
a  hearty  meal,  eaten  with  enjoyment,  and  completely 
assimilated. 

A  considerable  variety  in  foods  is  agreeable  to  many 
people.  This  fondness  for  variety  often  extends  to  a 
lack  of  appetite  and  loss  of  assimilating  powers  when  the 
same  cooking  is  eaten  day  in  and  day  out.  Moreover, 
a  wide  variety  of  foods  is  usually  an  insurance  against 
those  disease  conditions  associated  with  a  deficit  of 
vitamins. 

Cooking  of  Food.  To  a  large  extent  cooking  of  food 
is  a  matter  of  custom,  although,  of  course,  cooking  does 
make  the  food  more  tender,  —  that  is  —  more  easily 
acted  upon  by  the  digestive  juices.  But  from  the  view- 
point of  health  cooking  is  chiefly  important,  not  from 
any  modification  of  the  food,  but  because  it  kills  harm- 
ful bacteria  and  parasites.  Milk,  one  of  the  few  foods 
which  is  consumed  in  a  raw  state,  is  an  instance  of  how 
dangerous  an  uncooked  food  may  be.  Cooking  re- 
moves much  of  the  water  from  foods  and  also  some 
of  the  juices.  While  it  makes  meats  more  palatable, 


FOOD  53 

it  often  makes  them  slightly  less  digestible,  and  slightly 
less  rich  in  nutrients.  Vegetables  are  also  made  more 
palatable  and  the  structures  are  so  altered  as  to  make 
them  more  easily  digested.  Excessive  cooking  makes 
vegetables  both  unpalatable  and  indigestible.  The 
despised  fried  foods  deserve  their  bad  reputation  only 
to  the  extent  that  the  fat  added  may  be  unnecessary  or 
unpalatable.  But  on  the  whole  cooking  is  almost 
entirely  for  the  benefit  of  the  palate. 

Cost  of  Food.  Much  of  the  recent  discussion  of  foods 
has  been  devoted  to  the  high  cost.  As  a  matter  of 
fact  the  cost  of  eating  is  high,  because  custom  and 
fashion  demand  the  use  of  products  which  are  not  in 
themselves  of  unusually  great  caloric  value.  It  is 
perfectly  possible  to  arrange  a  satisfactory  diet  of 
sufficient  calories  at  a  low  cost  of  the  raw  materials. 
A  rice  diet  of  2,500  calories  can  be  obtained  for 
about  four  cents,  while  the  same  number  of  calories 
in  shad,  for  example,  would  cost  over  sixty  cents. 
What  can  be  done  in  the  way  of  procuring  food 
value  at  slight  cost  is  shown  in  the  lunches  which 
are  served  in  schools  where  the  cost  is  about  one  cent 
per  hundred  calories. 

The  main  cost  of  food  lies  not  so  much  in  the  cost 
of  the  raw  materials  as  in  the  preparation  and  service. 
The  poor  often  buy  prepared  foods  of  low  caloric  value 
and  at  considerable  expense  rather  than  the  raw  foods 
of  high  caloric  value  at  low  cost.  Then  in  the  case  of 
the  poorer  classes  the  cost  of  rent  is  fixed,  so  that  they 
economize  in  the  elastic  cost  of  food.  As  a  result 
the  poor  get  too  few  calories  and  the  consequent 
undernutrition  bears  an  important  relation  to  dis- 
ease. Poverty  markedly  affects  the  food  supply  of 
a  family,  and  yet  a  thorough  understanding  of  food 
values  would  permit  them  to  economize  on  food  and 
at  the  same  time  secure  adequate  calories.  The 


54  HEALTH  AND  DISEASE 

dissemination  of  such  knowledge  is  extremely  impor- 
tant and  should  be  begun  in  the  public  schools.  It 
is  vastly  more  essential  to  health  than  the  instruction 
in  cookery. 

Rations.  The  average  person,  through  the  expe- 
rience of  years  and  customs,  eats  a  well-balanced  diet  of 
sufficient  calories  and  pays  no  attention  to  food  analysis. 
Nevertheless  many  diets  are  being  arranged  almost 
solely  on  a  calorie  basis.  Scientific  methods  of  feeding 
have  been  introduced  into  schools,  hospitals,  and 
sanatoria  for  reasons  of  economy  and  for  reasons  of 
health.  All  armies  are  fed  on  this  principle,  for, 
obviously,  physical  efficiency  in  armies  is  absolutely 
essential.  Profiting  by  the  bitter  experiences  in  the 
past,  the  feeding  of  the  modern  army  in  the  field  rep- 
resents to-day,  especially  in  Europe,  a  splendid  example 
of  scientific  feeding.  Nothing  is  left  to  chance.  Each 
man  receives  a  ration  which  is  sufficient  for  the  average 
man  at  hard  work.  Such  a  diet  is  monotonous,  but 
there  is  often  opportunity  for  "extras",  usually  in  the 
form  of  foods  of  no  great  food  value,  but  which  give 
variety,  such  as  fresh  fruits  and  the  like.  These  rations 
allow  about  3,500  well-balanced  calories  a  day  and 
include  salt,  tea,  or  coffee.  In  addition,  there  are  in- 
cluded certain  articles  of  food  for  the  purposes  of  bulk 
and  to  supply  vitamins.  Such  articles  vary  from  the 
dried  vegetables,  often  made  into  soup,  to  the  vegetable 
sausage  of  the  German  army.  Bread  is  the  substance 
which  is  almost  inevitably  present  in  the  largest  amount, 
not  only  in  weight,  but  also  in  calories.  Bacon  is  a 
favorite  substance,  since  it  contains  both  protein  and 
fat.  Almost  any  diet  contains  considerable  meat, 
but  the  days  of  rations  almost  exclusively  of  beef,  salt 
pork,  and  bacon  have  long  since  gone,  as  such  an 
exclusively  protein  diet  was  accompanied  by  marked 
gastro-intestinal  disorders. 


FOOD  55 

An  interesting  ration,  made  up  to  include  sufficient 
well-balanced  calories  at  the  lowest  possible  cost,  is  the 
ration  furnished  by  the  Belgian  Relief  Commission. 
This  commission  had  the  problem  of  furnishing  to  large 
numbers  of  people  a  diet  which  should  keep  them  alive, 
prevent  disease,  and  yet  be  cheap.  The  daily  ration 
was  approximately  as  follows :  Bread  11  oz.  (or  its 
calorie  equivalent  in  flour) ;  rice  1^  oz. ;  dried  peas 
and  beans  f  oz. ;  bacon  £  oz. ;  coffee  f  oz. ;  lard  ^  oz. ; 
salt  ^  oz.,  sugar  ^  oz.  This  ration  was  given  to  each 
person,  —  men,  women,  and  children.  The  total  num- 
ber of  calories  is  about  1,400,  of  which  about  ten  per 
cent  are  protein.  This  diet  is  barely  sufficient  for 
life,  and  is  not  sufficient  for  hard  work,  but  it  was 
possible  for  the  Belgians  to  exist,  since  the  old,  the 
young,  and  the  small  doubtless  needed  less.  Prob- 
ably the  people  were  occasionally  able  to  add  vege- 
tables and  other  products  of  their  land  and  thus 
increase  the  food  value  of  their  diet  as  well  as  to  re- 
lieve the  monotony. 

General  Diets  and  Rations.  The  following  table 
gives  a  rough  estimate  of  a  typical  dietary  for  a  man 
leading  a  more  or  less  sedentary  life. 

APPROXIMATE 
CALORIES 

Breakfast 

Orange  or  grapefruit 100 

2  eggs 166 

2  Vienna  rolls 258 

butter 119 

coffee  with  milk  and  sugar     ....  100 

Total 743 

Luncheon 

12  soda  crackers 300 

1  pint  milk 325 

Total  .  625 


56  HEALTH  AND  DISEASE 

APPROXIMATE 
CALOEIES 

Dinner 

Soup,  consomme 14 

Roast  beef 357 

Potato        145 

String  beans  or  peas 13 

Bread    . 100 

Butter 119 

Apple  pie 352 

Glass  milk 157 

Total 1257 

These  figures  are  based  upon  average  servings  of  each 
food.  The  following  figures  show  the  approximate  cal- 
ories in  an  average  serving  of  the  more  common  foods. 
Strictly  accurate  figures  can,  of  course,  only  be  obtained 
by  weighing  each  article  of  food  and  determining  the 
exact  food  value  from  the  tables  showing  the  caloric 
values  of  the  articles  of  the  diet. 

APPROXIMATE 
CALORIES 

Average  serving  of : 

Roast  beef 350 

Beefsteak  (round) 185 

Chicken  (roast) 180 

Bacon 190 

Codfish 100 

Turkey 285 

Pea  soup ,  .  160 

Tomato  soup        125 

Butter 120 

American  cheese 90 

Baked  beans 300 

Baked  potato 150 

Apple 75 

Orange 95 

Strawberries 40 

Bread,  baker's 80 

Bread,  home  made 100 

Apple  pie 350 

Sugar  (cube) 30 

Peanuts  125 


FOOD  57 

In  the  breakfast  menu,  cereal  with  milk  and  sugar 
would  add  100  calories,  and  an  average  serving  of 
bacon  would  add  190  more.  In  the  luncheon  menu, 
cold  meats  with  vegetables  would  give  about  the  same 
total  of  calories.  If  black  coffee  replaced  the  milk  at 
dinner,  the  food  value  would  be  decreased,  for  coffee 
by  itself  has  no  caloric  value. 

Special  Diets.  In  general  terms  any  special  diet 
should  only  be  directed  towards  the  alleviation  of  some 
special  condition  and  should  always  be  under  expert 
supervision.  Many  people,  however,  fearlessly  under- 
take to  prescribe  diets  for  themselves,  their  families, 
friends,  and  even  casual  acquaintances.  The  general 
run  of  these  amateur  diets  may  be  classified  under  the 
rather  meaningless  caption  of  "  light  but  nourishing." 
Such  diets  are  popularly  assumed  to  be  appropriate  to 
minor  illnesses,  fatigue,  and  the  like  and  are  as  much 
a  part  of  the  household  armentarium  as  castor  oil. 
Few  of  these  diets  are  what  they  purport  to  be. 

There  are  a  few  simple  facts  upon  which  an  easily 
digested  nutritious  diet  can  be  based.  The  nourishing 
factor  of  food  depends  solely  on  the  food  values  and  on 
nothing  else.  Hence  jellies,  no  matter  how  palatable, 
depend  for  any  nourishing  quality  on  the  substances 
from  which  they  are  made,  and  most  of  the  jellies  have 
few  calories. 

A  completely  healthy  person  takes  care  of  all  the  food 
of  any  reasonable  diet,  but  in  ill  health  of  any  degree 
this  may  not  hold.  Fats  are  relatively  hard  to  assimi- 
late and,  furthermore,  much  fat  with  food  is  unap- 
petizing. Hence  the  natural  prejudice  against  greasy 
foods  and  fried  foods  comes  with  reason.  Likewise, 
pork  and  pork  products  and  veal,  which  contain  con- 
siderable fat,  are  harder  to  assimilate  than  beef. 
Furthermore,  all  food  to  be  assimilated  must  be  finely 
minced  in  the  organism.  Tough,  stringy  meats  require 


58  HEALTH  AND  DISEASE 

more  work  to  be  divided  finely  and  so  are  harder  to 
digest  than  tender  meats.  Cooking  helps  to  solve  this 
difficulty,  not  only  in  meats,  but  also  in  the  case  of 
grains  and  cereals.  It  stands  to  reason  that  if  the  first 
mechanical  step  of  bringing  food  to  a  point  of  mincing 
is  carried  out,  it  helps  digestion.  Such  is  the  reason  for 
the  preference  of  toast  or  zweibach  over  bread;  and 
old  bread  is  preferable  to  new  bread,  since  aging  after 
baking,  like  toasting,  helps  to  break  up  the  carbo- 
hydrates. 

Such  are  the  facts  which  make  for  an  easily  digested 
diet  whenever  one  is  required.  That  any  diet  should 
be  appetizing  goes  without  saying.  In  general  "  home 
made  diets  "  are  poor  things,  largely  because  they  have 
no  scientific  foundation  and  they  break  up  good  food 
habits.  Then,  too,  the  amateur  dietician  almost 
inevitably  considers  that  an  important  characteristic 
of  any  diet  is  limitation  of  food.  A  diet  based  on  this 
consideration,  even  if  correctly  composed  of  bland  and 
easily  digested  foods,  tends  to  constipation  since  the 
bulky  foods  of  low  caloric  value  are  usually  eliminated 
on  account  of  the  supposed  indigestibility.  It  is  wise, 
except  under  medical  direction,  to  stick  to  a  reasonable 
diet  of  sufficient  calories,  which  is  well  balanced  and 
which  contains  sufficient  bulk.  The  scales  and  our 
feelings  are  the  best  indices  for  our  guidance. 

Diets  for  Obesity  and  Leanness.  There  are  many 
so-called  diets  for  obesity  and  almost  as  many  for 
leanness,  all  depending  on  the  general  principles  of 
nutrition  presented  in  the  foregoing  pages.  The  prob- 
lem in  obesity  is  merely  the  limitation  of  food  values 
below  the  requirements  of  the  body  so  that  the  body 
burns  fat  tissue.  In  a  sense  this  procedure  is  partial 
starvation.  Purgation  may  be  employed  in  order  to 
hurry  the  food  through  the  digestive  tract  and  thus  re- 
duce absorption.  Furthermore,  fluids  may  be  restricted, 


FOOD  59 

again  in  order  to  hinder  the  absorption  of  food.  Occa- 
sionally a  substance  derived  from  the  thyroid  gland  is 
given,  for  this  increases  the  requirements  of  the  body. 
The  activity  of  the  obese  person  is  increased  merely  to 
increase  his  requirements  of  energy,  part  of  which 
must  come  from  his  food. 

The  problem  can  be  stated  mathematically :  the  cal- 
orie intake  minus  the  bodily  requirements,  largely 
influenced  by  exercise,  equals  the  answer.  If  the  answer 
is  plus,  the  person  will  tend  to  gain  weight.  If  the  an- 
swer is  zero,  the  weight  will  be  stationary ;  and  if  minus, 
the  person  will  be  compelled  to  use  his  tissues  as  food 
and  will  lose  weight.  From  the  viewpoint  of  the  indi- 
vidual the  success  of  the  treatment  depends  on  the  lack 
of  discomfort  and  the  bother  he  has  in  following  it. 
For  example,  if  a  person's  bodily  requirements  are  2,500 
calories,  to  get  thin  he  can  be  given  2,000  calories.  If  he 
takes  his  2,000  calories  in  concentrated  food,  —  bread, 
butter,  meat,  cheese,  and  sugar,  he  can  eat  very  little 
and  he  will  be  hungry.  On  the  other  hand  he  would 
have  to  eat  over  twenty  pounds  of  celery  a  day  to  get 
his  2,000  calories.  Consequently  he  fills  himself  with 
foods  of  a  low  value,  such  as  fruits,  all  the  green  vege- 
tabl.es,  and  the  like.  He  avoids  the  foods  with  a  high 
food  value,  such  as  sugar,  which  is  pure  carbohydrate, 
butter  and  oil,  which  are  pure  fat,  cheese,  bread, 
breakfast  foods,  and  meats.  Some  of  the  cures  for 
obesity,  like  the  milk  cure,  limit  the  individual  to  one 
article  of  diet.  Milk  is  not  a  concentrated  food,  as  it 
is  about  eighty-eight  per  cent  water  and  it  takes  about 
three  quarts  to  make  2,000  calories.  This  gives  the 
individual  about  twelve  glasses  of  milk  a  day,  which 
seems  like  a  generous  allowance.  Of  course  some  in- 
dividuals may  only  require  1,500  calories  a  day,  which 
merely  necessitates  putting  the  intake  below  that 
amount  in  order  to  lose  weight. 


60  HEALTH  AND  DISEASE 

A  word  of  warning  is  necessary  for  those  who  under- 
take weight  reduction  on  their  own  initiative.  The 
body  has  become  accustomed  to  the  increased  size  and 
also  to  the  diet  of  the  individual.  Sudden  losses  of 
weight  and  sudden  changes  in  the  diet  may  prove  to 
be  very  disturbing  to  the  entire  bodily  mechanism. 
Every  physician  has  seen  instances  of  nervous  break- 
down induced  by  such  incautious  violent  changes. 
After  weight  reduction,  it  is  usually  necessary  to  con- 
tinue careful  dieting  for  some  months,  since  any  in- 
crease in  the  food  intake  will  probably  be  accompanied 
by  a  gain  in  weight  and  the  attempt  to  restore  the 
previous  size  of  the  body.  But  after  the  weight 
has  been  stationary  for  a  considerable  period  and 
the  bodily  economy  accepts  the  low  level  as  fixed, 
minor  fluctuations  in  intake  usually  make  little  differ- 
ence. It  must  be  remembered  that  on  a  food  intake, 
fixed  approximately  at  the  bodily  requirements,  the 
weight  will  be  stationary  whether  the  person  is  lean 
or  fat. 

In  order  to  increase  the  weight  the  same  principles 
of  feeding  are  utilized  and  the  patient  reverses  the 
practices  outlined  for  the  treatment  of  obesity.  **  Stuf- 
fing," however,  has  very  definite  limitations,  as  every 
tuberculosis  sanatorium  has  experienced.  Nature  fre- 
quently rebels  at  persistent  stuffing.  This  procedure 
calls  for  the  ingestion  of  large  amounts  of  the  same  kind 
of  food  and,  usually,  of  considerable  fat.  The  value  of 
cod  liver  oil,  for  example,  is  mainly  its  high  food  value. 
Now  the  power  to  assimilate  fat  is  definitely  limited. 
By  the  use  of  food  tables,  however,  it  is  relatively 
simple  to  increase  markedly  the  food  values,  and 
through  their  use  the  common  mistakes  as  to  the 
values  of  foods  may  be  avoided.  The  following  brief 
table  gives  an  idea  of  the  food  value  of  a  pound  (500 
grams)  of  some  of  our  common  foods : 


FOOD  61 

Beefsteak 1130  calories 

Potatoes 385  calories 

Wheat  flour 1640  calories 

Butter 3636  calories 

Cheese 2285  calories 

Codfish 295-335  calories 

Lobster 130  calories 

Cabbage 145  calories 

Celery 85  calories 

Breakfast  foods 1700  calories 

Milk 325  calories 

Eggs 720  calories 

Canned  baked  beans 600  calories 

Roasted  peanuts 3177  calories 

English  walnuts 3305  calories 

Fads  and  Fancies  in  Foods.  It  seems  to  be  an  essen- 
tial characteristic  of  human  nature  to  desire  to  experi- 
ment with  food.  Of  course  such  experimentation  in 
the  past,  rather  than  science,  has  been  the  main  source 
of  our  knowledge  on  this  subject.  No  better  illustra- 
tion of  this  could  be  given  than  Lamb's  fanciful  account 
of  the  important  discovery  that  roast  pig  was  fit  for 
human  consumption.  And  it  is  to  be  expected  that 
as  people  have  always  experimented  with  their  diets, 
so  they  probably  always  will.  The  topic  of  food  ranks 
with  that  of  the  weather  as  a  never  failing  subject  of 
conversation  and  discussion.  Such  discussion  is  always 
personal.  But  it  should  be  remembered  that  the  indi- 
vidual experiment  is  of  no  value  when  it  runs  counter 
to  similar  experiments  which  number  thousands. 
Nearly  all  the  experiments  with  food  are  old  and  there 
are  ample  data  to  decide  as  to  their  wisdom  or  worthless- 
ness.  Apparently,  however,  people  like  to  diet,  usually 
on  their  own  initiative,  and  many  times  the  diet  which 
forms  the  basis  of  their  conversation  and  which  they 
pretend  to  like  to  keep  is  largely  a  fiction  or  is  mainly 
characterized  by  quiet  exceptions  which  **  they  do  not 
count." 


62  HEALTH  AND  DISEASE 

Vegetarianism.  Many  people  have  adopted  a  so- 
called  vegetarian  diet,  some  for  humanitarian  reasons, 
others  because  of  the  belief  that  it  is  better  for  the 
health.  It  is  not  a  non-protein  diet,  as  many  people 
think,  that  the  vegetarians  advocate  and  use,  but  a 
non-meat  diet.  The  cereals  and  grains  average  roughly 
about  ten  per  cent  of  the  food  value  from  the  protein 
content,  an  excellent  proportion.  Furthermore,  the 
protein  from  the  vegetable  is  the  source  of  the  animal 
protein.  The  meat  eater  gets  his  protein  in  part  from 
the  vegetable  kingdom,  and  in  part  from  the  animal 
kingdom  which  makes  it  from  the  vegetable  kingdom. 
Thus  the  difference  between  the  two  diets  is  not  so  great 
as  appears  at  first.  On  the  other  hand  it  is  probably 
true  that  meat  protein  is  somewhat  more  easily  taken 
care  of  than  vegetable  protein. 

While  no  absolutely  positive  statement  can  be  made, 
it  is  probably  desirable  that  man  should  use  both  the 
vegetable  and  animal  forms  of  protein.  Man  is 
naturally  an  omnivorous  creature.  While  some  animals 
are  exclusively  meat  eaters  and  others  exclusively 
herbivorous,  both  types  are  healthy.  For  food  ani- 
mals, including  man,  prefer  the  herbivorous  animal, 
since,  as  is  well  known,  the  carnivorous  animals  have  a 
so-called  strong  taste.  The  difference  is  in  palatability 
only.  It  is  extremely  doubtful  if  the  type  of  food  has 
any  determining  influence  on  the  ferocity  or  mild 
temper  of  man  or  beast.  Carnivorous  animals  slay  for 
food  and  not  for  lust.  The  ferocity  of  a  meat  eating 
animal  can  be  matched  by  that  of  the  herbivorous  ani- 
mal and  so,  too,  can  his  courage.  While  it  is  probably 
true  that  many  people  eat  too  much  meat  and  are 
harmed  by  it,  moderation  and  not  vegetarianism  is  the 
real  solution  of  the  difficulty.  Vegetarians  have  to 
face  the  difficulty  of  securing  a  properly  balanced  diet. 
This  is  particularly  true  if  they  exclude  eggs,  milk,  and 


FOOD  63 

the  milk  products  —  butter,  cream,  and  cheese.  They 
may  easily  increase  the  calories  by  taking  a  larger 
amount  of  sugar,  but  the  diet  will  be  unbalanced  and 
in  taking  a  carbohydrate  excess,  they  may  be  making 
trouble  for  themselves.  A  glance  at  the  dietary  tables 
will  show  that  this  difficulty  is  by  no  means  insurmount- 
able, especially  if  they  add  to  their  diet  peas  and  beans 
and  similar  foods  which  are  particularly  rich  in  protein. 

Vegetarianism,  it  is  true,  has  its  advantages.  For 
one  thing,  it  almost  inevitably  supplies  sufficient  bulk 
and  so  there  is  rarely  any  trouble  from  constipation. 
It  is  also  true,  as  the  exponents  of  vegetarianism  claim, 
that  certain  vegetarians  can  perform  any  of  the  mental 
or  physical  feats  which  meat-eaters  can.  Undoubtedly 
many  people  would  be  benefited  by  taking  more  food 
from  the  vegetable  kingdom,  but  strict  vegetarianism 
cannot  be  recommended.  Nature  apparently  intended 
us  to  be  omnivorous,  and,  in  addition,  vegetarianism 
runs  too  close  to  the  dangers  of  carbohydrate  excess. 

Fletcherism  So-called.  In  recent  years  a  food  fashion 
of  prolonged  mastication  of  a  limited  amount  of  food 
has  been  revived.  Like  vegetarianism,  Fletcherism 
represents  a  revolt,  more  or  less  wholesome  in  modera- 
tion, against  the  tendencies  of  bolting  food  and  over- 
eating. It  is,  of  course,  desirable  that  the  food  be 
properly  minced  before  it  is  swallowed.  Mastication 
is,  in  addition,  good  for  the  teeth  and  mouth.  Yet 
many  toothless  or  nearly  toothless  individuals  enjoy 
good  health  provided  the  food  is  somehow  subdivided. 
So  there  is  no  basis  in  science  or  experience  for  excessive 
mastication. 

The  limitation  of  food  under  the  system  of  Fletcher 
has  to  meet  the  fact  that  the  bodily  requirements  deter- 
mine the  number  of  calories  necessary  and  that  the 
amount  of  food  and  the  number  of  calories  are  not 
necessarily  parallel.  Most  people  wisely  prefer  a 


64  HEALTH  AND  DISEASE 

margin  of  safety  in  the  amount  of  food.  When  neces- 
sary, it  is  granted,  certain  persons  can  maintain  life  on 
a  small  number  of  calories,  nevertheless,  if  the  activity 
of  the  body  burns  up  a  certain  number  of  calories,  that 
number  of  calories  must  be  supplied  from  the  food,  and, 
failing  that,  from  the  tissues,  —  a  condition  which 
amounts  to  partial  starvation.  A  limitation  of  food 
below  the  bodily  requirements  in  disease  or  in  health,  by 
starvation,  either  voluntary  or  involuntary,  whether 
under  the  guise  of  a  food  fad  or  not,  is  inevitably 
harmful. 

Other  Fads.  Among  recent  fads  is  the  so-called 
buttermilk  or  sour  milk  diet  as  advocated  by  Metch- 
nikoff.  The  original  theory  was  interesting  and  was, 
in  part,  that  the  bacteria,  which  soured  milk,  could  drive 
out  of  the  intestinal  canal  all  the  harmful  bacteria. 
By  taking  buttermilk  or  the  artificial  preparation  made 
by  fertilizing  milk  with  cultures  of  lactic  acid  bacilli, 
in  the  first  place,  one  is  taking  food.  In  the  second 
place  these  preparations  are  all  slightly  laxative  and, 
since  many  people  are  chronically  slightly  constipated, 
the  effect  is  beneficial.  One  may,  in  part,  especially  if 
large  quantities  of  milk  be  taken  with  the  lactic  acid 
bacilli,  supplant  the  bacteria  which  do  not  find  milk  so 
favorable  a  medium  for  growth  as  the  lactic  acid 
bacilli.  The  beneficial  effect  of  this  change  of  bacteria 
is  probably  not  of  great  consequence. 

White  Meat,  Red  Meat,  and  Fish.  Red  meat  comes 
periodically  into  violent  disrepute.  Popular  opinion 
holds  it  to  be  the  active  cause  of  rheumatism  and  most 
of  the  various  ills  of  the  flesh.  Outside  of  minor 
differences  of  a  technical  character,  there  is  little  differ- 
ence, chemically  or  in  any  other  way,  between  red  and 
white  meat.  The  same  statement  holds  true  of  the 
meats  of  various  animals  —  beef,  chicken,  and  fish. 
The  real  consideration  is  the  amount  of  protein  con- 


FOOD  65 

sumed.  Fish  contains  considerably  more  water  than 
animal  meat  and  is,  consequently,  less  rich  in  protein, 
weight  for  weight.  It  is  also  obviously  easier  to  eat 
more  protein  in  a  beafsteak  than  from  squab,  but 
protein  value  for  protein  value  there  is  little  difference. 

Predigested  Foods.  The  predigested  foods  of  which 
we  read  and  hear  so  much  have  little  to  recommend 
them.  All  foods  have  to  undergo  changes  before  they 
are  absorbed  and  many  of  these  changes  are  still  un- 
known to  us.  Food  can  be  prepared  mechanically  and 
thus  by  being  minced  or  softened  be  more  ready  for  the 
action  of  the  digestive  juices,  but  there  is  no  evidence 
that  any  chemical  preparation  of  food  (this  is  what 
predigested  foods  mean)  assists  to  any  appreciable 
extent  the  assimilation  of  food. 

Candy.  Most  of  us  have  been  brought  up  in  the 
belief  that  candy  is  bad  for  us,  but  scientific  studies 
have  proved  the  contrary  to  be  the  case.  Candy  is, 
or  should  be,  practically  pure  sugar,  and  has,  therefore, 
a  high  caloric  value.  The  objection  to  candy  is  that 
it  is  usually  eaten  at  the  wrong  time,  between  meals  — 
and  so  impedes  digestion.  Saccharine  may  be  used 
in  place  of  sugar  as  a  sweetening  agent,  but  this  sub- 
stance has  absolutely  no  food  value. 

A  word  should  suffice  to  dismiss  all  the  old  supersti- 
tions concerning  the  particular  value  of  certain  foods  for 
certain  functions.  None  of  these  beliefs  has  the  slightest 
foundation  in  fact.  They  are  all  as  groundless  as  the 
belief  that  the  eating  of  fish  creates  mental  ability. 

Preservation  of  Food.  Under  our  present  conditions 
of  life  it  has  become  necessary  for  us  to  find  ways  for 
preserving  food,  for  only  a  small  part  of  what  we  eat 
is  fresh  and  has  not  had  to  be  transported  long  dis- 
tances. A  glance  at  the  articles  of  our  table  tells  us 
that  the  orange  may  come  from  Florida  or  California, 
the  banana  from  further  away,  the  tea  or  coffee  from 


66  HEALTH  AND  DISEASE 

China  or  Brazil,  the  meat  is  usually  Chicago  beef,  and 
so  on.  The  inhabitants  of  our  largest  cities  would 
starve  if  preservation  of  food  had  not  made  its  transpor- 
tation for  long  distances  possible. 

The  preservation  of  food  depends  upon  only  one  prin- 
ciple, the  elimination  of  as  many  bacteria  as  possible, 
for  it  is  the  presence  of  bacteria  that  causes  nearly  all 
the  changes  which  we  know  as  spoiled  food.  The  par- 
ticular kind  of  food  determines  the  kind  of  preservation 
necessary.  Tea,  coffee,  sugar,  and  flour,  for  example, 
are  dry  substances  and  are  preserved  in  ordinary  dry 
vessels.  Bacteria  like  moisture  (many  of  them  require 
moisture)  and  they  usually  require  air.  Since  there 
are  bacteria  in  the  air,  air-tight  packages  often  suffice 
for  the  indefinite  preservation  of  certain  foods,  provided 
that  they  are  bacteria-free  originally. 

The  use  of  cold  or  cold  storage  is  the  most  important 
method  of  preservation  of  food  which  we  use.  Cold 
prevents  the  growth  of  bacteria,  but  it  may  not  actually 
kill  them.  It  has  been  shown  that  food  which  is  kept 
cold  all  the  time  is  not  harmed ;  only  a  certain  amount 
of  the  fresh  taste  is  removed  but  all  the  nutritive  values 
are  retained.  But  food  should  not  be  allowed  to  become 
warm  and  then  be  placed  in  the  cold  again.  If  this  is 
done,  the  bacteria  may  grow  rapidly  and  certain  changes 
may  take  place  which  make  the  food  unfit  for  human 
consumption  and  may  cause  disease. 

Eggs  are  now  commonly  preserved  in  cold  storage. 
If  placed  directly  in  the  cold,  when  they  are  fresh,  they 
keep  for  years  without  spoiling  or  losing  their  food  value. 
Eggs  may  be  preserved  by  other  methods,  the  most  com- 
mon being  to  paint  them  with  shellac  to  keep  out  the  air, 
for  bacteria  in  the  air  can  penetrate  into  an  egg-shell. 
Eggs  may  be  tested  for  freshness  by  the  candle  method 
or  by  floating  them  in  a  briny  solution.  Fresh  eggs  are 
evenly  translucent  and  will  not  float.  Cold  storage 


FOOD  67 

eggs  have  a  peculiar  flavor,  but  they  are  as  nutritious 
as  fresh  eggs  and  do  not  cause  disease.  Indeed,  while  a 
few  people  are  susceptible  to  eggs  and  are  poisoned  by 
them,  there  are  few  cases  reported  where  disease  has 
been  caused  by  eggs. 

The  second  method  of  preserving  food  is  the  already 
mentioned  method  of  keeping  it  free  from  air.  This  is 
done  in  the  case  of  canned  or  bottled  goods,  although 
most  canned  goods,  in  addition,  are  heated  and  the 
bacteria  killed  before  the  can  is  sealed.  Practically 
everything  may  be  preserved  by  this  method,  for,  if 
the  food  is  put  up  without  air,  it  is  practically  impossible 
for  the  ordinary  forms  of  bacteria  to  grow  and  thus 
cause  decay.  Furthermore,  the  possibility  of  the  intro- 
duction of  bacteria  by  the  air  is  eliminated.  The  tin 
used  in  canned  food  is  practically  harmless,  and  there 
have  never  been  any  cases  of  poisoning  due  to  canning. 
The  unpleasant  experiences  in  the  Spanish-American 
war  were  due  to  the  fact  that  the  food  was  bad  when  it 
was  placed  in  the  cans.  The  claim  is  often  made  that 
the  best  foods  are  usually  sold  fresh  and  that  the  second 
grade  products  are  used  in  canning.  With  the  tre- 
mendous growth  of  this  industry  and  with  increased 
facilities  of  transportation  many  canneries  raise  foods 
for  the  express  purpose  of  canning,  so  that  they  use  the 
best  products.  Canned  goods,  however,  do  give  an 
opportunity  for  the  adulteration  of  food,  a  common 
illustration  being  the  use  of  copper  to  make  peas  look 
green.  This  in  itself  is  not  harmful,  but  is  unnecessary, 
as  are  the  other  methods  used  to  make  canned  goods 
resemble  the  fresh  article.  Canned  goods  should  be 
served  shortly  after  being  opened,  or  else,  with  the 
inevitable  introduction  of  bacteria,  they  will  spoil 
rapidly.  The  dangers  from  canned  goods  are  merely 
the  dangers  which  arise  from  dishonesty  and  carelessness 
and  these  can  be  eliminated  by  inspection. 


68  HEALTH  AND  DISEASE 

The  third  method  of  preserving  food  is  by  drying. 
A  good  illustration  of  this  is  pemmican,  which  consists 
of  strips  of  meat  cut  into  thin  slices  and  dried  carefully. 
Vegetable  matter  and  fats  may  be  added  so  as  to  give  a 
balanced  diet.  This  prepared  pemmican  can  be  kept 
for  a  long  time  without  spoiling.  Beef  and  vegetables 
can  be  preserved  by  drying,  for,  as  a  result  of  the  loss 
of  moisture,  bacteria  find  it  difficult  to  increase  and 
thus  spoil  the  food. 

Food  is  also  preserved  by  the  use  of  preservatives, 
which  either  kill  the  bacteria  or  hinder  their  growth. 
This  method  was  rampant  a  few  years  ago,  but,  due  to 
considerable  publicity,  it  has  practically  ceased  as  far 
as  the  injurious  preservatives  are  concerned.  Boric 
acid,  salicylic  acid,  and  formalin  are  some  of  the  com- 
mon preservatives.  In  large  amounts  all  these  sub- 
stances are  detrimental  to  health  and  some  seriously 
affect  the  food.  With  the  increasing  use  of  preservation 
by  cold  and  by  canning,  there  is  no  place  for  such 
methods.  Salt  is  a  common  preservative,  especially 
in  the  case  of  fish,  which,  preserved  in  this  way,  will 
keep  for  years.  Sugar  is  the  ordinary  preservative 
used  for  fruits,  while  alcohol  is  frequently  used  for  many 
foods. 

Smoking  is  a  perfectly  harmless  method  of  preserving 
food,  but  it  is  limited  entirely  to  meats,  as  smoked  ham 
and  beef,  and  to  fish. 

The  final  method  of  preserving  food  is  by  cooking, 
that  is  by  cooking  thoroughly.  Any  thoroughly  cooked 
food  is  safe,  for  the  bacteria  are  all  killed  and  the  food 
will  keep  indefinitely,  provided  that  other  bacteria  do 
not  enter.  This  method  is  used  in  connection  with 
canning.  Partial  heating,  or  pasteurization,  is  used  to 
preserve  beer  and  milk.  Evaporated  or  sterilized  milk 
is  preserved  in  sealed  vessels  after  the  bacteria  have 
been  killed  by  heat. 


FOOD  69 

Bacteria  and  Food.  In  discussing  the  preservation  of 
food  the  importance  of  excluding  bacteria  from  food,  of 
hindering  their  growth  there,  and  of  killing  them  in  food 
wherever  possible  has  been  emphasized.  The  effect  of 
bacteria  on  food  varies  with  the  kind  of  bacteria  and 
with  the  kind  of  food.  Fish,  for  example,  is  a  good 
culture  medium  for  bacteria  on  account  of  its  chemical 
composition,  especially  the  high  water  content,  and, 
furthermore,  bacteria,  and  harmful  bacteria  at  that, 
find  easy  access  into  fish.  A  not  unusual  action  of  bac- 
teria on  fish  is  to  make  it  highly  poisonous.  Hence 
fish  should  be  eaten  as  fresh  as  possible  and  well 
cooked.  On  the  other  hand  few  of  us  like  our  beef 
too  fresh.  If  kept,  certain  changes,  partly  chemical 
and  partly  bacterial  in  origin,  soften  the  fiber  and 
make  it  more  tender  and  more  palatable.  But  this 
same  flavor,  like  the  highly  regarded  "  gamey  "  flavor 
of  certain  game  birds,  is  merely  the  beginning  of 
the  process  of  spoiling  or  putrefaction.  If  the  meat 
is  cooked  thoroughly,  the  bacteria  are  killed  and  the 
changes  in  the  meat  do  not  interfere  with  its  nutritive 
value  nor  do  they  cause  disease.  In  cheese,  however, 
bacteria  are  allowed  to  grow  and  the  flavor  depends 
on  the  partial  decomposition  induced  by  the  bacteria. 
The  fermentation  of  wine  and  the  souring  of  milk 
are  also  due  to  bacteria,  but  their  presence  and  the 
partial  decomposition  of  the  food  are  not  necessarily 
harmful. 

In  general,  preserved  foods  have  the  same  food  value 
as  the  raw  product.  This  is  particularly  true  of  cold 
storage  foods,  as  such  foods  are  unchanged.  In  dried 
foods,  since  the  water  is  removed,  the  food  is  concen- 
trated and,  consequently,  the  food  value  is  higher.  In 
food  preserved  by  sugar,  the  sugar,  of  course,  introduces 
a  substance  of  high  food  value.  Unlike  most  foods 
which  are  little  changed  by  preserving,  milk  is  consider- 


70  HEALTH  AND  DISEASE 

ably  altered,  due  to  the  fact  that  prolonged  heat  is 
necessary  to  evaporate  the  water.  The  Food  and  Drug 
Act  has,  fortunately,  put  a  stop  to  the  sale  of  many 
of  the  condensed  milks  which  were  originally  merely 
skimmed  milk  and  sugar.  Improvement  in  the  methods 
of  preserving  milk  promises  to  offer  us  either  an  evapo- 
rated milk,  or,  preferably,  a  powdered  milk  (since  dry 
milk  is  less  subject  to  bacterial  contamination)  which 
can  be  used  safely. 

It  is  impossible  to  say,  with  accuracy,  that  one 
method  of  preservation  is  better  than  another.  The 
deciding  factor  is  the  food  to  be  preserved.  Often  a 
combination  of  methods  is  used,  since  all  aim  at  the 
same  result  —  that  of  preventing  the  growth  of  bacteria. 
When  foodstuffs  can  be  so  treated,  heating  to  kill  the 
bacteria,  and  sealing,  as  in  a  can,  and  then  the  main- 
tenance of  cold  afford  every  security  for  the  wholesome- 
ness  of  the  preserved  food. 

It  is  often  difficult  or  impossible  to  predict  with  cer- 
tainty whether  a  partially  decomposed  food  will  disturb 
the  human  organism  or  not.  This  disturbance  depends 
on  the  nature  of  the  bacteria  and  the  changes  in  the 
food. 

The  safeguarding  of  food  depends,  in  the  first  place, 
on  the  careful  inspection  of  the  original  food  supply, 
i.e.  the  animals  used  as  food  should  be  healthy.  Then 
there  must  be  adequate  sanitary  care  in  the  treatment 
of  all  food  products.  Preserved  foods,  in  particular, 
should  be  supervised  carefully  throughout  their  entire 
course. 

Food  may  cause  disease  because  the  material  itself  is 
poisonous,  as  is  the  case  with  mushrooms.  Or  it  may 
happen  that  the  food  has  acquired  certain  poisons,  as 
is  instanced  in  the  case  of  the  partridge  which  has 
eaten  some  substances  that  do  not  poison  the  partridge, 
but  the  bird,  when  eaten,  is  highly  poisonous. 


FOOD  71 

The  Pure  Food  Law.  The  Pure  Food  Law,  about 
which  we  have  heard  so  much,  is  not  a  pure  food  law 
at  all,  but  simply  a  law  to  prevent  misbranding.  The 
law  was  not  actually  passed  as  a  health  measure,  but 
as  a  protection  to  certain  industries,  notably  farming. 
Substitutes  for  farm  products  may  be  excellent  for  food, 
but  they  ought  to  be  sold  as  substitutes.  Oleomar- 
garine, for  instance,  is  as  high  in  food  value  as  butter  and 
there  is  no  reason  why  people  should  not  eat  it.  The 
only  point  is  that  oleomargarine  should  be  sold  as  oleo- 
margarine and  not  as  pure  butter.  The  Pure  Food  Law 
does  prevent  the  indiscriminate  introduction  of  extra- 
neous and  possibly  harmful  substances  into  food  prod- 
ucts. The  law  is  a  step  towards  honest  products,  and 
health  depends  largely  on  honesty. 

Food  and  Disease.  In  addition  to  the  diseases 
already  mentioned  as  caused  by  food,  there  are  two 
other  types  of  food  poisoning :  (1)  In  which  the  food 
merely  acts  as  the  carrier  of  disease  bacteria;  (2)  in 
which  certain  changes  in  the  food  have  been  caused  by 
bacterial  origin  and  the  eater  is  poisoned  primarily  by 
the  changed  food  and  not  by  the  bacteria. 

Under  the  first  heading,  in  which  the  food  acts  as  the 
carrier  of  disease  germs,  are  included  the  diseases  which 
may  be  carried  by  milk  and  water,  such  as  typhoid  fever, 
cholera,  tuberculosis,  septic  sore  throat,  and  the  like. 
Milk  and  water  are  so  important  to  the  individual  and 
the  community  from  the  point  of  view  of  health  and 
sanitation  that  separate  chapters  are  devoted  to  them. 
There  is  a  form  of  paratyphoid  fever  (like  typhoid 
fever)  which  is  frequently  carried  by  sausages,  and 
which  was  formerly  known  as  sausage  poisoning. 
Other  intestinal  diseases  due  to  special  bacteria  are  less 
commonly  caused  by  the  presence  of  bacteria  in  the  food. 
Thorough  cooking,  to  which  sausage  are  not  always 
subjected,  will  kill  the  bacteria  and  prevent  disease. 


72  HEALTH  AND  DISEASE 

Two  diseases  are  derived  from  food  and  in  no  other 
way,  trichiniasis  and  tapeworm  disease.  Trichiniasis 
is  caused  by  minute  animal  parasites  —  trichinae  - 
in  pork  which  appears  measly  when  the  parasites  are 
present.  Fortunately  they  are  entirely  destroyed  by 
proper  cooking  of  the  pork,  but  otherwise  they  get  into 
the  body  and  cause  muscular  rheumatism.  Properly 
inspected  pork  will  not  contain  trichinae.  The  other 
animal  parasite  of  importance  in  this  connection  is  the 
tapeworm.  Beef,  pork,  and  fish  each  has  a  special 
tapeworm.  The  beef  tapeworm  is  the  most  common 
in  this  country.  These  parasites  are  also  killed  by 
proper  cooking.  Consequently  if  all  our  food  were 
cooked  thoroughly  and  not  contaminated  subsequently, 
these  diseases  due  to  animal  parasites  could  not  be 
transmitted  by  food. 

Tuberculosis  may  be  carried  by  food,  usually  milk. 
Typhoid  fever  is  not  a  disease  of  the  lower  animals  and 
so  it  can  get  into  food  only  through  gross  contamination 
in  handling.  Careless  and  unsanitary  methods  of 
handling  food  are  the  cause  of  many  diseases.  But  the 
problem  of  food-handling  is  only  a  problem  in  decent 
handling.  Clean  hands  are  an  essential  in  this  proce- 
dure. The  principle  of  infection  is  the  same  as  that 
which  made  people  do  away  with  the  common  drinking 
cup  and  the  roller  towel. 

There  is  a  considerable  group  of  diseases  due  to 
changes  in  food  and  to  the  changed  food.  This  group 
includes  a  number  of  complex  conditions.  We  have 
little  definite  knowledge  of  this  whole  subject,  not 
much  more  in  fact  than  the  person  who,  when  he  has 
diarrhea  in  the  summer,  boldly  complains  that  he  has 
ptomaine  poisoning  and  is  quite  satisfied  with  his 
diagnosis.  Some  of  the  cases  of  ptomaine  poisoning 
are  due  to  the  fact  that  the  food  carries  special  bacteria ; 
others  are  merely  anaphylaxis.  But  others  remain, 


FOOD  73 

chiefly  occurring  during  hot  weather,  when  food  is 
difficult  to  keep,  which  are  best  explained  as  follows. 
For  some  reason,  probably  largely  due  to  bacterial 
action,  a  food  breaks  up  into  different  parts.  While 
the  food,  as  a  whole,  is  not  poisonous,  some  of  the  parts 
may  be.  This  is  particularly  true  of  protein  foods. 
All  protein  foods  can  be  broken  up  and  furnish  some 
substance  which  is  highly  poisonous.  The  result  of  the 
action  of  a  poisonous  fraction  of  food  is  called  ptomaine 
poisoning.  Since  we  have  known  more  about  bac- 
teriology, we  know  that  many  cases  of  ptomaine  poi- 
soning, so  called,  are  really  cases  of  paratyphoid  fever, 
dysentery,  and  the  like,  and  that  the  disease  germs  enter 
the  body  through  water  or  food,  although  the  water  or 
the  food  in  themselves  were  fundamentally  wholesome. 

Conclusions  about  Food.  The  problem  of  food  in 
relation  to  health  seems  complicated,  but,  in  reality, 
the  solution  is  simple.  The  important  considerations 
are :  a  reasonable  knowledge  of  food  values  and  food 
balance ;  an  appreciation  of  the  importance  of  bulk 
and  fresh  foods ;  the  establishing  of  good  food  habits  in 
regard  to  regularity  of  eating  and  water  drinking,  and 
the  insistence  upon  the  ordinary  principles  of  decent 
cleanliness  from  the  source  of  the  food  to  the  consumer. 

Bacterial  contaminations  of  food  and  the  early  spoil- 
ing of  food  depend  on  unclean  methods  somewhere. 
Official  organized  inspection  is  necessary  away  from 
home,  but  care  in  the  household  is  just  as  important. 
Since  our  living,  our  activity,  and  our  health  depend 
upon  food,  a  better  understanding  of  food  should  lead 
to  a  longer  life,  increased  activity,  and  better  health. 


CHAPTER 
Am 

As  is  the  case  with  food,  our  present-day  opinions 
concerning  the  air  are  far  different  from  those  held 
only  a  few  years  ago.  We  now  know  that  an  abundant 
supply  of  moving,  pure,  fresh  air  is  the  proper  and 
simple  solution  of  the  problem  of  the  hygiene  of  the 
air.  With  the  confirmation  of  this  relatively  simple 
belief,  the  mysteries  and  the  superstitions  of  former 
years  have,  to  a  large  extent,  vanished. 

Air  is  the  most  necessary  element  for  life,  as  we  can 
live  for  only  a  few  moments  unless  the  process  of  res- 
piration continues.  In  respiration  we  take  in  oxygen 
from  the  outside  air  and  give  back  to  the  air  carbon 
dioxide.  Food,  as  has  been  stated,  is  burned  to  supply 
the  body  with  heat  and  energy  so  that  the  bodily  pro- 
cesses may  go  on.  For  this  combustion,  as  is  the  case 
in  any  burning,  oxygen  is  necessary.  Thus  respiration 
supplies  us  with  oxygen  for  the  burning  of  our  food  and, 
when  the  combustion  has  taken  place,  gives  off  the 
waste  products. 

Metabolism  Cycles.  The  process  of  combustion  in 
the  animal  organism  discloses  interesting  cycles  which 
involve  nearly  the  whole  scheme  of  Nature.  In  the 
carbon  cycle,  for  instance,  we  take  in  oxygen  and  give 
off  carbon  dioxide.  The  carbon  dioxide  thus  passed 
off  into  the  air  is  taken  up  by  all  kinds  of  plants. 
Many  of  these  plants  are  edible  and  are  eaten  by 
animals  for  their  carbohydrates.  The  plants  have 
worked  over  the  carbon  dioxide,  for  their  own  pur- 

74 


AIR  7T 

poses,  into  sugars  and  starches,  and  the  latter  are  taken 
by  man  for  food.  With  the  creation  and  utilization 
of  energy  and  heat  carbon  dioxide  is  given  off  again. 

The  so-called  nitrogen  cycle  is  also  interesting. 
Nitrogen  is  the  basis  of  all  protein  food.  Plants  take  up 
nitrogen,  either  directly  from  the  air  which  is  four-fifths 
nitrogen  or  from  the  soil.  A  rich  soil  has  a  large  amount 
of  nitrogen  which  has  come  from  the  decomposition  of 
protein  and  other  nitrogenous  substances  which,  in 
breaking  down,  put  nitrogen  into  the  soil.  The  nitrogen 
is  taken  up  by  plants,  and  this  plant  nitrogen  or  protein 
may  be  taken  directly  into  the  human  system  or  may  be 
taken  up  by  animals  and  as  animal  protein  into  the 
human  system.  The  last  step  is  the  use  of  the  protein  to 
build  up  muscle  or  tissue.  The  cycle  then  begins  anew. 

In  the  oxygen  cycle,  oxygen  is  taken  from  the  air 
by  the  human  body  and  is  given  off  in  the  form  of 
carbon  dioxide.  The  latter  is  taken  up  by  plants. 
The  unused  oxygen  is  given  off  again.  This  carbon 
dioxide,  the  refuse  from  the  respiration  of  animals,  is 
the  main  constituent  of  air  that  is  utilized  by  plants. 

Composition  of  Air.  Air  is  a  mixture  of  gases,  of 
which  oxygen  and  nitrogen  are  the  most  important. 
The  air  contains  from  twenty  to  twenty-one  per  cent 
of  oxygen,  while  nitrogen  makes  up  most  of  the  re- 
mainder. The  usual  amount  of  carbon  dioxide  is 
only  three  parts  in  10,000,  so  that  the  amount  of  this 
gas,  about  which  we  have  heard  so  much,  in  ordinary 
air  is  actually  very  small. 

The  difference  in  percentages  between  inspired  and 
expired  air  is  shown  by  the  following  table : 


OXYQEN 

NITROGEN 

CARBON  DIOXIDE 

Inspired  air     

20.81 

79.15 

0.03 

16.033 

79.557 

4.38 

HEALTH  AND  DISEASE 

air  is,  of  course,  warmer  than  the  in- 
is  more  moisture,  but  fewer  particles  of 
the  conditions  of  ordinary  respiration 
,  no  bacteria. 

Oxygen  is  the  element  of  the  air  which  sustains  life. 
We  inhale  about  seven  pounds  per  day  and  about  two 
pounds  of  this  are  absorbed  by  the  body.  When  the 
oxygen  in  the  air  decreases  to  only  eleven  or  twelve  per 
cent,  the  air  becomes  dangerous,  and,  when  the  oxygen 
reaches  seven  per  cent,  death  results  from  asphyxia- 
tion. Even  in  the  worst  ventilated  rooms  the  oxygen 
is  rarely  much  lowered  and  asphyxiation  practically 
only  takes  place  when  some  other  gas  is  substituted 
for  air. 

Asphyxiation  may  be  caused  by  the  inhaling  of 
illuminating  gas,  but,  in  this  case,  death  is  usually 
due  to  the  poison  carbon  monoxide.  In  war  death  has 
been  caused  by  chlorine  gas,  which  is  heavy  and  rolls 
along  the  ground,  displacing  the  air.  The  victim 
strangles  to  death  as  in  drowning.  There  is,  of  course, 
the  irritant  and  the  poisonous  effect  of  the  gas  itself, 
for  chlorine  is  extremely  irritating  to  the  lungs.  Other 
extraneous  gases  may  poison  the  organism  without 
causing  irritation  or  mechanical  suffocation. 

The  nitrogen  in  the  air  merely  serves  as  a  diluent 
of  the  oxygen  and  thus  regulates  the  rate  of  combus- 
tion. The  animal  mechanism  uses  it  in  no  way. 

Humidity.  Moisture  is  an  ever-present  factor  in 
the  air,  for  moisture  is  given  off  by  everything  which 
breathes.  An  adult  person  gives  off  about  four  pounds 
of  watery  vapor  every  twenty-four  hours,  two  and  a 
half  pounds  through  the  skin  and  one  and  a  half  pounds 
through  breathing.  Growing  plants  and  trees  also 
throw  off  an  immense  amount  of  moisture.  The 
presence  of  this  water  or  moisture  in  the  air  —  the 
condition  known  as  humidity  —  has  a  considerable 


AIR  77 

effect  upon  health.  The  proper  amount  of  humidity  is 
from  fifty  to  fifty-five  per  cent  of  the  amount  of  mois- 
ture which  the  air  can  take  up  at  that  temperature. 
An  increase  of  27°  F.  of  temperature  doubles  the 
capacity  of  the  atmosphere  to  take  up  moisture.  The 
precipitation  of  dew  is  a  familiar  illustration  of  the 
inability  of  cold  air  to  retain  as  much  moisture  as 
warm  air. 

As  we  all  know  from  experience,  humidity  increases 
the  effect  of  heat  and  cold  on  the  body.  On  hot  days 
when  the  humidity  is  high  —  "  muggy  days  "  —  the 
heat  is  unusually  oppressive.  Places  near  the  sea  or 
water  areas  are  apt  to  have  a  high  humidity,  and,  in 
hot  seasons,  the  inhabitants  suffer  greatly  with  the 
heat  and,  in  cold  seasons,  the  effect  of  the  cold  is  in- 
tensified. In  deserts  and  other  dry  areas  with  a  low 
humidity,  temperatures  of  110°  F.  are  not  so  uncom- 
fortable as  a  temperature  of  85°  with  a  high  humidity. 

This  question  of  moisture  in  the  air  is  of  vital  im- 
portance in  the  heating  of  our  houses.  In  artificially 
heated  houses  the  humidity  is  generally  too  low,  for 
the  house  can  be  kept  at  a  lower  and  more  comfortable 
temperature  if  the  amount  of  moisture  is  increased. 
In  addition,  the  individual  is  much  better  off  if  there 
is  a  certain  amount  of  moisture  in  the  air.  Before  the 
air  can  go  to  the  lungs,  it  must  be  properly  moistened, 
as  well  as  heated,  by  the  nose  and  throat.  Many  of 
the  colds  which  occur  in  winter  find  their  origin  in  the 
dry  heat  of  rooms  without  any  moisture,  which  keeps 
the  nose  and  throat  irritated  and,  therefore,  liable  to 
infection. 

If  moisture  is  to  be  artificially  added  to  the  air,  it 
should  be  to  the  warm  air  and  not  to  the  cold  air,  for 
cold  air  saturated  with  moisture  will  show  a  low  humid- 
ity when  the  air  becomes  warm.  Most  of  our  systems 
of  heating  make  no  allowance  for  supplying  moisture. 


78  HEALTH  AND  DISEASE 

Several  devices  to  accomplish  this  purpose  have  been 
attempted,  but  none  of  them  has  been  sufficiently 
perfected  for  general  use  in  small  houses.  A  simple 
method  of  improving  the  humidity  is  by  placing  a 
pan  of  water  on  the  radiator.  Another  effective  method 
is  by  keeping  plants  and  flowers  in  our  rooms,  for  they 
always  contain  and  exhale  a  considerable  supply  of 
moisture. 

Dust.  Dust,  or  suspended  dry  particles,  is  another 
substance  which  is  always  present  in  the  air.  If  there 
were  no  dust  whatever,  there  would  be  no  rain,  no  fog, 
and  no  clouds.  The  moisture  of  the  air  is  taken  up 
by  the  suspended  particles  of  dust,  and,  if  these  particles 
were  not  present,  there  would  be  precipitated  moisture 
over  everything.  This  dust  is  made  up  of  many  kinds 
of  animal  and  vegetable  matter,  but  the  important 
elements,  from  the  viewpoint  of  hygiene,  are  the  collec- 
tions of  bacteria  and  the  so-called  droplets  which  are 
borne  about  in  the  air.  These  droplets  are  active 
factors  in  the  spread  of  disease.  When  a  person  coughs 
or  sneezes,  moisture  and  droplets  are  thrown  off  and 
by  these  small  droplets  bacteria  are  carried  to  other 
people.  This  is  the  so-called  droplet  method  of  in- 
fection. 

Dust  should  be  controlled  as  much  as  possible,  if 
for  no  other  reason  than  to  prevent  the  irritation  of  the 
air  passages.  All  dusting  in  the  house  should  be  done 
with  moist  cloths  or  with  a  vacuum  cleaner  which 
actually  removes  the  dirt.  Streets  should  also  be 
cleaned  in  a  way  which  will  not  create  dust. 

Sewer  Gas.  No  discussion  of  the  air  is  complete 
without  reference  to  sewer  gas.  Thirty  or  more  years 
ago,  before  we  knew  anything  about  bacteriology, 
sewer  gas  was  supposed  to  cause  many  of  the  human 
ills.  Even  to-day  this  superstition  has  not  entirely 
disappeared.  Sewer  gas  is  decidedly  unpleasant  to 


AIR  79 

the  smell,  but  it  probably  carries  no  more  organisms 
than  ordinary  air,  and,  like  ordinary  air,  is  dangerous 
only  on  account  of  the  bacteria.  Of  itself  sewer  gas  is 
harmless ;  it  is  simply  a  bad  odor.  The  effect  of  odors 
or  bad  smells  on  health  is  not,  it  must  be  admitted, 
well  understood.  Unpleasant  odors  diminish  the 
amount  of  air  inhaled,  while  pleasant  odors  usually 
cause  us  to  take  deeper  breaths.  All  air  has  various 
odors  which  are  detected  and  differentiated  by  the 
lower  animals.  Through  civilization,  however,  our 
sense  of  smell  has  decreased  in  acuteness,  and  we  be- 
come rapidly  accustomed  to  any  unusual  odor. 

Ozone.  Ozone  is  another  constituent  of  the  air, 
but,  so  far  as  we  know,  it  is  of  little  moment.  In 
concentrated  form  ozone  kills  bacteria  and  is  an  irri- 
tant to  the  body,  but  it  is  not  present  in  the  air  in  suffi- 
cient quantities  to  have  any  effect  either  one  way  or 
the  other. 

Atmospheric  Pressure.  Atmospheric  pressure  is  an 
important  consideration  in  hygiene.  At  sea  level  a 
man  of  average  size  is  subjected  to  about  fifteen  tons 
of  atmospheric  pressure  and  all  the  bodily  functions 
are  adjusted  to  this  pressure  which  itself  is  probably 
a  considerable  factor  in  the  operation  of  many  of  them. 
The  fact  that  people  have  considerable  difficulty  in 
breathing  on  the  tops  of  mountains  is  familiar,  and  this 
difficulty  is  caused  by  the  change  in  pressure  of  the 
atmosphere.  Atmospheric  pressure  is  like  any  other 
form  of  pressure  —  it  represents  a  certain  amount  of 
weight.  When  a  man  climbs  a  mountain,  simply  be- 
cause he  has  less  miles  of  atmosphere  weighing  down 
on  him,  the  amount  of  pressure  is  less.  Then  hemor- 
rhages may  occur,  because  the  blood  is  accustomed  to 
being  held  back  by  a  greater  pressure.  Nothing  can  be 
done  to  prevent  this  condition  and,  as  a  rule,  accommo- 
dation soon  occurs.  The  difficulty  in  breathing  is  in 


80  HEALTH  AND  DISEASE 

getting  the  proper  amount  of  oxygen.  Our  systems 
are  tuned  up  to  the  extraction  of  a  certain  amount  of 
oxygen  at  a  given  pressure.  If  the  air  pressure  is 
diminished,  the  extraction  of  oxygen  is  more  difficult 
and  we  have  to  breathe  more  rapidly  to  get  the  same 
amount  of  oxygen. 

In  passing  through  a  tunnel  one  may  experience  a 
certain  amount  of  headache,  due  to  the  increased 
amount  of  atmospheric  pressure.  This  pressure  may 
even  cause  actual  sickness.  Men  who  work  under  in- 
creased atmospheric  pressure  are  subject  to  "  caisson 
disease."  The  treatment  of  this  disease  is  to  bring 
the  sufferer  back  into  ordinary  air  pressure,  gradually 
and  not  too  fast.  If  the  pressure  is  slowly  increased 
by  passing  through  several  chambers  with  increasing 
pressures  and  as  slowly  released,  the  workers  usually, 
but  not  always,  avoid  the  ill  effects  of  the  increased 
air  pressure. 

Air  as  a  Cooling  Agent.  Air  is  used  for  two  principal 
purposes,  —  breathing  and  for  cooling  purposes.  The 
old  view  which  was  held  concerning  air  was  that  such 
things  as  sewer  gas  and  carbon  dioxide  were  of  great 
moment  in  the  so-called  "  bad  air."  As  a  matter  of 
fact  the  effects  of  bad  air  are  due,  primarily,  to  the 
interference  of  the  cooling  of  the  body  by  the  air. 
Men  have  been  put  into  places  where  the  air  was  bad 
and  foul  and,  as  they  felt  injurious  effects,  it  was  de- 
cided that  these  effects  were  due  to  the  inspiration  of 
poisonous  gases.  But  experiments  have  been  made  in 
which  the  body  remained  in  the  bad  air  and  the  nose 
out  of  a  window.  The  bad  effects  continued.  The 
conclusion  from  this  is  that  the  bad  effects  were  due  to 
the  interference  with  the  cooling  of  the  human  machine 
by  air.  Bad  air  is  hot  and  moist  both  from  the  breath- 
ing and  from  contact  with  the  human  body.  This 
moist  heat  interferes  with  the  cooling  of  the  body. 


AIR  81 

While  the  bad  effects  of  crowded  rooms  are  largely  due 
to  the  interference  with  the  cooling  of  the  body,  the  pres- 
ence of  large  numbers  of  bacteria  in  the  air  makes 
infection  easily  possible.  Disagreeable  odors  add  to 
the  discomfort.  No  matter  how  much  air  is  breathed 
and  re-breathed  in  such  a  place,  the  amount  of  oxygen 
is  not  reduced  materially.  In  mines  oxygen  may  be 
reduced,  but  in  buildings  the  amount  of  oxygen  re- 
mains constant. 

The  amount  of  air  which  the  body  requires  is  about 
3,000  cubic  feet  per  hour.  The  problem  of  ventilation 
is  to  give  this  amount  of  pure  air,  moving,  and  with  the 
proper  amount  of  moisture.  If  the  air  is  still,  the  body 
becomes  surrounded  by  a  warm,  moist  envelope  which 
causes  over-heating.  Moving  air  equalizes  the  tem- 
perature and  the  moisture.  Our  own  feelings  are  the 
best  registers  of  the  freshness  or  badness  of  air.  We 
are  certain  that  the  amount  of  carbon  dioxide  will 
never  be  sufficient  to  cause  asphyxiation,  but  the 
estimation  of  the  carbon  dioxide  content  of  air  gives 
accurate  information  as  to  how  well  the  air  is  changed 
and  it  is,  therefore,  of  considerable  importance. 

Climate.  We  hear  a  great  deal  about  the  effects  of 
climate  on  health,  but,  in  reality,  we  know  little  about 
climate.  Without  a  doubt  many  people  are  benefited 
by  warmth  and  sunlight,  but  this  may  well  be  as  much 
a  mental  as  a  physical  benefit.  Climate  indirectly  af- 
fects the  health  by  making  people  feel  better  through 
being  out-of-doors.  But  this  is  the  effect  upon  the 
temperament  rather  than  any  wonderful  thing  in  the 
air.  On  the  other  hand,  there  is  a  certain  amount  of 
evidence  that  people  with  some  diseases  do  better  in 
particular  climates.  For  years  consumptives  have  gone 
to  Colorado  and  regained  their  health  ;  other  consump- 
tives have  done  the  same  at  home.  Still  the  consump- 
tive seems  to  do  better  in  the  high,  dry  air,  which  is, 


82  HEALTH  AND  DISEASE 

perhaps,  due  to  the  physical  effect  of  a  low  atmospheric 
pressure  and  a  low  humidity.  Just  how  these  condi- 
tions act  we  do  not  know. 

The  ills  attributed  to  climate  are  often  due  to  bacte- 
ria and  parasites.  Tropical  countries  have  been  con- 
sidered unhealthy  on  account  of  the  presence  of  malaria 
and  yellow  fever,  but  these  diseases  are  due  solely  to 
the  presence  of  mosquitoes  which  carry  the  diseases. 
Swampy  air  does  not  cause  malaria,  but  the  bite  of  a 
malaria-infected  mosquito  that  lives  in  the  swamp 
is  the  causative  agent.  A  certain  relation  does  seem 
to  exist,  however,  between  the  physical  factor  of  in- 
creased humidity  and  certain  rheumatic  conditions. 

Another  superstition  in  regard  to  air  is  that  night  air 
is  injurious.  The  only  difference  between  night  air 
and  day  air  is  that  night  air  lacks  sunlight.  The 
chemical  difference  between  any  airs  is  practically  nil. 
Thus  in  out-of-door  sleeping  the  benefit  derived  is  not 
due  to  the  difference  in  the  air,  but  to  the  tonic  effects 
of  the  colder  air  outside.  The  beneficial  effect  of  this 
cold  air  has  been  demonstrated  in  the  treatment  of 
various  diseases.  But  in  such  treatment  the  effect  of 
sunlight  on  the  body,  as  yet  undetermined,  must  not 
be  underestimated  and  this  action  is  entirely  independ- 
ent of  the  air. 

Deep  Breathing.  We  commonly  think  that  we  are 
filling  our  lungs  with  fresh  air  at  each  breath.  Such 
is  not  the  case,  for  we  never  get  our  lungs  filled  with 
fresh  air.  What  we  do  is  to  ventilate  a  long  tube  which 
has  no  interchange  whatever  with  the  blood.  Most 
of  the  time  our  lungs  are  filled  with  bad  air,  and  we 
simply  exchange  a  part  of  it  for  fresh  air.  Thus,  if  a 
person  breathes  rapidly,  he  is  doing  a  great  amount  of 
work  which  is  practically  useless,  for  slow  breathing 
is  the  more  economical  method.  Deep  breathing  is 
undoubtedly  extremely  beneficial.  Most  of  us,  due 


AIR  83 

to  the  fact  that  Nature  leaves  a  considerable  margin 
of  safety,  are  able  to  carry  on  our  ordinary  activities 
without  the  requisite  ventilation  of  the  lungs,  especially 
if  we  do  not  exercise.  This  is  injurious  to  the  lungs  for 
it  allows  the  blood  to  stagnate  in  them.  Exercise  is 
Nature's  method  of  compelling  ventilation  in  the  lung 
area.  Deep  breathing  may  be  used  as  a  substitute, 
but  the  other  beneficial  effects  of  exercise  are  lost. 

Drafts.  Although  moving  air  is  necessary  for  well- 
being,  when  air  becomes  so  violent  in  movement  that 
we  are  conscious  of  it  we  call  it  a  draft  in  the  house 
and  a  breeze  outside  and  consider  the  condition  some- 
what dangerous  to  health.  Once  and  for  all  drafts 
do  not  cause  colds.  Bacteria,  and  bacteria  alone,  are 
the  cause.  However,  if  one  part  of  the  body  is  cool 
while  the  rest  is  warm,  as  in  the  case  of  a  draft,  or  if 
the  entire  body  is  allowed  to  be  cooled  suddenly  and 
continuously,  as  in  a  breeze,  the  whole  heat-regulating 
apparatus  of  the  body  is  upset  and  this  may  predispose 
to  colds.  But  in  the  absence  of  the  cold-causing  bac- 
teria, no  exposure  to  drafts  and  no  chilling  will  cause 
a  cold. 

Conclusion.  The  importance  of  air  is  two-fold :  as 
a  carrier  of  oxygen  and  as  a  cooling  apparatus.  The 
ill-effects  of  "  bad  air  "  are  apparently  largely  due  to 
the  inability  of  bad,  stagnant  air  to  cool  the  body. 
In  breathing  bad  air  the  main  danger  seems  to  be  the 
increased  danger  of  infection. 


CHAPTER  IV 

THE  SKIN 

Functions  of  the  Skin.  The  skin  and  the  various 
glands  connected  with  it  form  a  complex  organism  with 
functions  of  great  importance  in  the  work  which  the 
body  has  to  do.  These  functions  may  be  classified  as 
protective,  sensory,  respiratory,  heat-regulating,  and 
secretory.  The  skin  protects  the  body  from  injuries 
from  without  and  also  acts  as  a  guard  against  a  too 
rapid  loss  of  the  liquids  and  heat  from  within.  Thus 
the  skin  protects  the  muscles,  nerves,  and  blood  vessels 
from  such  dangers  as  might  be  caused  by  blows  or 
pressure,  as  well  as  from  the  injurious  effects  of  high  and 
low  temperatures.  As  the  skin  forms  a  sensory  cover- 
ing to  the  body,  it  conveys  the  sensations  of  pressure, 
temperature,  and  pain  so  that  the  body  may  adapt 
itself  to  changes  in  its  environment.  The  skin  aids  the 
lungs  in  their  work  of  respiration  and,  like  the  lungs, 
throws  off  water  and  carbon  dioxide,  and  absorbs  oxygen. 
The  respiratory  work  done  by  the  skin,  however,  is 
only  a  minute  fraction  of  that  which  the  lungs  do. 

The  heat-regulating  function  of  the  skin  is  its  most 
important  work.  In  this  the  skin  is  aided  by  the  two 
million  or  more  sweat-glands  which  are  distributed 
over  almost  the  entire  surface  of  the  body.  The  skin 
and  the  sweat-glands  together  serve  to  keep  the  blood 
at  an  even  temperature,  either  by  giving  off  heat  or  in 
preventing  this  process  in  case  the  outside  air  is  too 
cool.  The  body  temperature  is,  as  a  rule,  higher  than 

84 


THE  SKIN  85 

that  of  the  outside  air  so  that  heat  is  generally  being 
given  off  by  the  skin.  We  are  perspiring  constantly, 
but  usually  to  such  a  slight  extent  that  we  hardly 
notice  the  fact.  The  amount  of  heat  which  is  thrown 
off  at  any  time  is  proportional  to  the  amount  of  the 
body  surface.  Through  exercise  the  amount  of  heat  is 
increased  and  sweat  is  produced  and  given  off.  Thus 
sweating  is  merely  another  method  of  getting  rid  of 
heat.  The  body  becomes  too  hot,  either  through  an 
increased  burning  of  food  and  tissue  within,  or  because 
of  increased  heat  outside.  In  either  case  sweat  is 
produced  and  collects  on  the  skin.  It  is  estimated  that 
fifteen  per  cent  of  the  total  heat  of  the  body  is  given  off 
through  the  skin,  and  ten  per  cent  by  the  lungs. 

The  condition  of  the  air  influences  the  amount  of 
work  which  the  sweat-glands  do  and  the  amount  of 
perspiration  thrown  off.  If  the  air  is  full  of  moisture, 
the  perspiration  does  not  evaporate  and  the  heat  be- 
comes excessive.  If  the  air  is  dry,  the  perspiration 
evaporates  rapidly  and  the  body  is  cooled.  Over  one 
liter,  or  one  quart,  of  perspiration  is  thrown  off  by  the 
skin  every  twenty-four  hours.  While  the  skin  and  its 
glands  keep  the  heat  of  the  body  well  regulated,  the 
changes  of  climate  are  so  great  that  animals  are  pro- 
vided with  hair  for  further  protection  against  the 
changes  in  temperature.  On  the  other  hand,  man 
uses  clothes  for  this  purpose.  Perspiration  may  be 
caused  by  other  things  than  by  heat  and  exercise. 
The  nervous  system  is  an  important  factor,  as  the  "cold 
sweat  "  of  fright  shows. 

The  sweat  and  sebaceous  glands  are  the  secretory 
glands  of  the  skin,  which  secrete  the  water  and  fats  that 
the  skin  needs  very  badly  to  keep  it  lubricated  and  in  a 
working  condition.  This  fat  or  grease  is  furnished  by 
the  sebaceous  glands.  If  a  person  has  greasy  hair,  it 
means  that  the  sebaceous  glands  of  the  hair  have  an 


86  HEALTH  AND  DISEASE 

over-secretion  of  grease.  These  glands  form  an  addi- 
tional layer  of  fat  on  the  surface  of  the  skin,  and  the 
oily  substance  from  them  protects  the  skin  from  losing 
a  large  quantity  of  heat. 

The  proper  hygiene  of  the  skin  depends  upon  a  wise 
selection  of  food,  a  proper  amount  of  exercise,  careful 
attention  to  bathing,  and  suitable  clothing.  The  func- 
tions of  the  skin  may  be  impeded  by  neglect  of  any 
of  these  essentials,  but  absolute  cleanliness  is,  perhaps, 
the  most  imperative  of  all. 

Clothing.  The  matter  of  clothes  is  not  one  of  vital 
moment  in  the  care  of  the  health.  Clothes  were  not 
originally  intended  for  the  purpose  of  keeping  warm, 
but  rather  to  increase  the  sexual  attractiveness  of  the 
individual.  As  we  have  become  civilized,  however, 
we  have  lost  sight  of  the  original  idea  of  clothes,  and 
they  are  now  worn  as  a  matter  of  decency  and  to  keep 
the  body  warm. 

As  an  important  function  of  air  is  to  act  as  a  cooling 
apparatus,  clothes  should  never  interfere  with  this. 
Clothes  should  be  sufficiently  loose  to  allow  a  reasonable 
circulation  of  air  around  the  body.  This  means  that 
the  air  should  have  free  access  to  the  skin,  and  that  all 
outer  clothes  should  be  loose  and  porous.  Tight  clothes 
interfere  with  the  normal  functions  of  the  parts  of  the 
body  which  they  cover.  We  are  coming  to  realize 
more  and  more  the  benefits  of  wearing  as  few  clothes 
as  possible,  and  only  the  minimum  amount  that  will 
secure  warmth  should  be  worn. 

In  selecting  clothing  to  be  worn  for  the  preservation 
of  heat,  it  should  be  remembered  that  certain  colors 
attract,  while  others  reflect  heat.  Black  absorbs  heat 
to  the  greatest  extent,  and  white  the  least.  The  more 
nearly  white  the  clothes  the  better. 

Wool  makes  the  most  desirable  articles  of  clothing, 
for  it  is  not  only  warm  but  it  also  absorbs  moisture,  — 


THE   SKIN  87 

an  important  point.  But  as  woolen  cloth  does  not 
give  off  moisture  rapidly,  it  is  undesirable  for  under- 
clothing, as  the  retained  perspiration  works  to  the  dis- 
advantage of  the  skin.  Cotton  cloth  is  preferable 
during  hot  weather,  as  it  does  not  keep  the  body  warm, 
and,  being  thin,  allows  a  proper  circulation  of  air. 
All  animal  coverings  are  warm,  due  to  the  fact  that  in 
addition  to  the  highly  impervious  skin  layer  there  is 
also  considerable  air  in  the  mesh  of  the  coat.  The 
same  result  may  be  obtained  with  layers  of  paper,  for 
with  the  air  spaces  between  the  layers,  there  is  little 
conduction  of  heat. 

It  is  perhaps  unnecessary  to  add  that  clothing 
should  be  kept  clean  and  well  aired.  Damp  clothing 
aids  the  growth  of  micro-organisms  and,  helped  by  the 
heat  of  the  body,  favors  the  development  of  parasitic 
skin  diseases. 

Bathing.  The  presence  of  perspiration  and  grease 
from  the  glands  makes  it  imperative  that  the  skin  be 
cleaned  carefully  in  order  that  it  may  freely  perform  its 
functions.  The  relation  of  baths  to  health  is  a  curious 
one,  for  we  cannot  say  that  baths  are  absolutely  essential 
to  health.  To  a  certain  extent  it  is  true  that  bathing 
is  largely  for  cosmetic  purposes  and  only  indirectly 
for  purposes  of  hygiene.  The  hands,  the  face,  and 
finger  nails,  however,  must  be  washed  with  care,  espe- 
cially before  meals  and  before  food  is  prepared.  This 
rids  the  surface  of  the  skin  of  any  kind  of  infection 
which  may  be  present.  Neglect  of  such  precautions 
is  responsible  for  the  spread  of  various  bacterial  and 
parasitic  diseases.  Soap  dissolves  the  products  of  the 
glands,  which  may  remain  on  the  skin  and  which  may 
prevent  their  doing  their  proper  work. 

A  cold  bath  has  a  stimulating  effect  on  the  body.  It 
sends  the  blood  to  the  skin,  increases  the  heart  action, 
warms  the  body,  and  gives  a  good  circulation  of  blood 


88  HEALTH  AND  DISEASE 

throughout  the  body.  This  means  that  the  cold  bath 
has  stimulated  the  metabolism  of  the  body  in  every 
way.  But  the  value  of  the  cold  bath  should  not  be 
over-emphasized  —  it  is  simply  a  method  of  stimula- 
tion. If  the  cold  bath  is  too  prolonged  or  too  cold, 
the  body  is  chilled  and  the  heat-regulating  mechanism 
is  disturbed  with  possible  bad  effects.  Some  persons 
are  easily  affected  by  cold  baths,  —  their  systems  do 
not  react,  so  that  cold  baths  are  harmful  to  them. 

A  warm  bath,  on  the  contrary,  acts  as  a  sedative. 
It  is  slightly  warmer  than  the  body  and  so  relieves  the 
work  of  the  body  for  a  time.  The  most  important 
thing  about  all  baths  is  the  securing  of  personal  cleanli- 
ness, which  is  best  obtained  by  the  use  of  hot  water 
and  soap.  It  should  be  remembered,  however,  that  a 
prolonged  hot  bath  which  disturbes  the  heat-regulating 
mechanism  is  harmful. 

Under  ordinary  conditions  the  skin  remains  smooth 
and  requires  little  real  attention.  The  natural  mois- 
ture and  oil  provided  by  the  glands  keep  it  lubricated 
and  soft.  Still  the  skin  may  be  disturbed  in  a  number 
of  ways.  One  is  by  mechanical  conditions  such  as  heat 
and  cold.  Burns  illustrate  the  effect  of  too  great 
heat,  while  the  effects  of  cold  run  all  the  way  from 
chapped  hands  to  the  freezing  of  different  parts  of  the 
body. 

The  Skin  and  Diet.  There  is  considerable  contro- 
versy over  the  effect  of  diet  upon  the  skin,  but  there  is 
no  question  that  it  has  a  certain  influence.  When 
people  take  an  insufficient  amount  of  water,  the  skin 
becomes  too  dry.  Then  in  the  case  of  an  abnormal 
skin  diet  plays  a  considerable  part.  The  classical 
example  is  the  satiny  skin,  the  pimples,  and  the  red 
nose  as  the  result  of  alcoholic  excess.  Such  effects, 
however,  should  be  regarded  as  the  result  of  the  use  of 
a  poison.  Drugs,  which  should  always  be  regarded 


THE  SKIN  89 

as  poisons,  cause  skin  trouble.  Among  such  drugs  are 
potassium  iodide  and  potassium  bromide.  Even 
quinine  may  cause  a  skin  rash.  Furthermore,  it  is 
known  that  constipation  causes  a  muddy  skin  or  acne. 

We  may  also  take  in  certain  poisons  in  our  food, 
which  cause  skin  trouble.  In  the  case  of  anaphylaxis, 
where  certain  individuals  are  susceptible  to  definite 
kinds  of  food,  one  of  the  evidences  of  the  poison  is  the 
rash  known  as  the  hives.  Of  course  the  avoidance  of 
that  kind  of  food  is  the  treatment  in  such  a  case. 

Disturbances  of  the  Skin.  Pimples,  or  acne,  is 
caused  by  a  disorder  of  the  sebaceous  glands.  Usually 
there  is  first  an  overactivity  of  the  glands,  and,  subse- 
quently, some  infection  of  them.  The  evidence  of  this 
disease  is  the  familiar  greasy,  dull  brownish  skin,  with 
pimples,  blackheads,  and  pustules.  It  is  especially 
striking  that  acne  is  prevalent  just  at  the  time  or  just 
after  the  time  of  reaching  puberty.  This  is  due  to 
the  increased  activity  and  growth  of  the  hair  on  the 
body  and  face  at  that  period  of  growth.  With  the 
development  of  hair  follicles  comes  the  development  of 
the  sebaceous  glands,  but  in  young  women  the  sebaceous 
glands  of  the  face  may  become  overactive  without  an 
increase  of  hair.  This  abnormal  activity  or  restlessness 
of  the  skin  is  greatly  increased  by  poor  habits  of  hygiene. 
Probably  much  of  this  trouble  comes  through  a  badly 
regulated  diet.  At  any  rate  people  are  aware  that  so 
long  as  they  keep  in  good  condition  and  take  good  care 
of  themselves  there  is  little  likelihood  of  acne.  In 
other  words,  ordinary  hygiene,  a  reasonable  diet,  regular 
meals,  regular  hours,  and  the  scrupulous  care  of  the 
bowels,  is  the  best  prevention  and  cure  of  acne.  Local 
applications  under  medical  supervision  are,  of  course, 
of  great  value. 

Eczema  causes  approximately  one-fifth  of  all  the 
skin  troubles.  This  condition  of  the  skin  is  also 


90  HEALTH  AND  DISEASE 

known  as  salt  rheum,  and  is  characterized  by  a  variety 
of  appearances,  perhaps  most  commonly  by  red,  weep- 
ing surfaces,  itchy,  red  pimples,  and  rough,  thickened 
areas.  We  are  ignorant  of  the  exact  cause  of  the  disease 
and,  consequently,  there  is  no  particular  prevention. 
At  present  eczema  is  ascribed  by  some  authorities  to 
an  inability  to  digest  certain  kinds  of  foods,  which  thus 
produce  substances  that  come  to  the  skin  and  irritate 
from  within.  It  is  probable  that  in  some  cases  eczema 
has  an  association  with  the  external  irritation  of  the 
skin,  and  so  care  should  be  taken  to  protect  the  skin 
from  scratching  and  other  irritations.  The  treatment 
of  eczema  varies  in  different  cases  and  should  be  placed 
under  the  care  of  a  physician  at  the  first  appearance 
of  the  disease.  Early  treatment  is  imperative,  for, 
in  this  stage,  the  disease  yields  readily,  but,  if  it  be- 
comes deep-seated,  it  may  be  very  difficult  to  eradicate. 

Associated  with  the  sebaceous  activity  in  acne,  is 
another  condition  known  as  dandruff,  and  allied  with 
that  the  condition  known  as  baldness.  Heredity  plays 
a  large  part  in  producing  baldness,  and  in  certain 
families  baldness  occurs  almost  inevitably  at  an  early 
age  despite  any  and  all  treatment.  This  is  probably 
due  to  the  fact  that  the  vigor  of  the  hair  dies  out. 
Baldness  is  also  caused  by  dandruff  and  a  poor  condi- 
tion of  the  scalp.  It  is  hardly  necessary  to  say  that  the 
hair  and  head  should  be  kept  clean,  but  continual 
shampooing  does  more  harm  than  good  except  in  a 
few  isolated  cases.  It  is  a  safe  rule  never  to  put  on 
the  scalp  anything  but  the  simplest  things,  and  sham- 
pooing at  intervals  of  two  or  three  weeks  is  usually 
sufficient  to  keep  the  hair  in  good  condition. 

In  certain  families  there  is  a  tendency  for  the  hair  to 
turn  gray  or  white  at  an  early  age.  There  is  practically 
nothing  that  can  be  done  to  prevent  this.  Hair  dyes 
should  never  be  used.  In  case  lead  hair  dyes  are  used 


THE  SKIN  91 

there  is  an  excellent  chance  of  contracting  lead  poison- 
ing, and,  in  any  event,  nearly  all  hair  dyes  injure  the 
hair  and  irritate  the  scalp. 

Other  inflammatory  conditions  of  the  skin  —  the 
various  forms  of  dermatitis  —  are  well  known  to  every- 
one. The  inflammation  caused  by  poison  ivy  is  a 
familiar  form  of  dermatitis.  Most  people  are  suscep- 
tible to  this  poison,  but  certain  individuals  are  more 
likely  to  be  affected  seriously  than  others.  One 
attack  of  ivy  poisoning  seems  to  add  to  the  suscep- 
tibility. The  fuzz  of  brown-tail  moths  also  causes 
an  uncomfortable  form  of  itching  dermatitis.  Furs 
which  have  been  kept  in  preservatives  also  cause 
irritation,  but  this  can  be  prevented  by  keeping  the 
furs  clean. 

A  number  of  the  disturbances  of  the  skin  are  conta- 
gious. A  common  infection  is  the  wart,  although  we 
do  not  know  how  the  infection  is  carried  nor  what  the 
cause  may  be.  There  have  even  been  epidemics  of 
warts  in  various  schools.  Numerous  superstitions 
have  arisen  concerning  warts  —  the  lore  of  every  boy 
and  girl  —  due  to  the  fact  that  warts  disappear  suddenly 
and  with  no  apparent  reason.  There  is  no  way  to 
prevent  warts  except  the  ordinary  prevention  of  any 
infection,  —  cleanliness.  It  is  not  always  wise  to  have 
warts  cut  off  or  burned  away  with  acid,  for  Nature 
will  usually  take  care  of  them  and  then  no  unsightly 
scar  remains. 

"  Red  flap  "  is  an  infection  of  the  skin  that  is  espe- 
cially common  on  the  athletic  field.  This  starts 
between  the  legs  or  under  the  arm-pits  as  a  seeming 
irritation.  This  is  really  an  infection  by  a  certain 
mold.  Once  started  the  contagion,  which  is  easily 
carried  by  such  articles  as  towels,  may  spread  to  all 
members  of  the  athletic  team.  As  it  is  contagious,  it 
should  be  treated  like  any  other  contagion,  that  is  by 


92  HEALTH  AND  DISEASE 

segregation  of  the  individual  sufferer.  The  prevention 
is  by  scrupulous  cleanliness  of  body  and  clothes,  and 
cleanly  habits  in  the  use  of  towels. 

Boils,  another  form  of  skin  infection,  are  caused  by 
a  definite  bacterium,  the  staphylococcus  aureus.  This 
is  a  pus-forming  bacterium  which  occurs  widely  and 
often  lurks  on  the  surface  of  the  skin.  Once  the  bac- 
terium gets  into  the  skin  it  may  be  difficult  to  dis- 
lodge. Boils  occur  commonly  on  the  back  of  the  neck 
and  there  is  a  definite  reason  for  this.  The  rubbing 
of  the  collar  starts  the  trouble;  then  the  germ  gets 
into  the  skin,  and  a  pimple  is  formed.  If  this  pimple 
is  irritated,  the  germs  are  spread  still  further,  and  a 
boil  is  formed.  If  the  sufferer  is  particuarly  unlucky, 
a  carbuncle  may  result.  The  spreading  of  boils  is 
extremely  easy,  but  it  is,  nevertheless,  due  to  gross 
carelessness.  There  is,  of  course,  a  degree  of  individual 
susceptibility.  The  avoidance  of  boils  is  simply  a 
matter  of  strict  personal  hygiene  and  cleanliness,  as 
well  as  the  recognition  of  the  fact  that  the  germs  may 
be  spread  all  over  the  body  and  transmitted  to  others. 
The  most  frequent  method  of  transmission  of  the  germs 
is  by  the  hands,  and  the  conclusion  here  is  the  obvious 
one  of  scrupulous  personal  hygiene.  Boils  are  a  typi- 
cal example  of  a  skin  infection  which  comes  from 
a  germ  and  finds  an  opening  through  an  irritation  of 
the  skin. 

The  "  seven  years  itch  "  or  scabies  is  another  example 
of  skin  infection  for  which  personal  cleanliness  is  the 
only  preventive.  This  condition  causes  much  annoy- 
ance if  it  is  not  treated  both  immediately  and  drasti- 
cally. It  is  popularly  supposed  that  the  "  seven  years 
itch  "  is  a  condition  which  does  not  occur  in  the  higher 
conditions  of  society,  but  such  is  not  the  case.  It  is 
caused  by  a  small  animal  parasite  that  burrows  in  the 
skin.  That  this  itch  spreads  easily  from  person  to 


THE  SKIN  93 

person  is  shown  by  the  tremendous  prevalence  of  scabies 
in  the  armies  of  France  during  1914  when  bathing  facili- 
ties were  deficient. 

Other  animal  parasites,  such  as  lice,  which  cause 
skin  lesions,  and  other  molds,  such  as  ringworm,  can 
be  avoided  by  ordinary  habits  of  cleanliness.  Such 
personal  cleanliness  should  include  not  only  contact  with 
other  human  beings,  but  also  with  the  lower  animals, 
for  ringworm  is  often  spread  by  the  domestic  animals. 
The  treatment  of  these  conditions  is  a  matter  for  medi- 
cal advice  in  each  instance. 


CHAPTER  V 

EXERCISE  AND  WORK 

The  Function  of  Exercise.  Physical  work  begins 
at  birth,  and,  in  various  ways,  continues  on  through 
life.  The  child  plays,  the  youth  indulges  in  sports, 
and  the  adult  works.  While  a  large  amount  of  physical 
work  is  done  even  when  a  person  is  at  rest,  the  heart 
is  two  or  three  times  as  active  under  conditions  of 
extreme  physical  activity.  We  are  all  familiar  with 
the  fact  that  when  we  take  a  great  deal  of  physical 
exercise  we  feel  hot,  and  thus  the  generation  of  heat  is 
one  of  the  effects  of  such  work.  We  sometimes  at- 
tempt to  keep  warm  by  physical  activity,  but  only 
ten  per  cent  of  the  heat  of  the  body  is  generated  in 
this  way.  Most  of  our  food  goes  to  make  heat  and  to 
create  motion,  eighty  per  cent  being  used  in  the  heat- 
forming  process.  This  is  the  reason  why  a  man  who 
leads  a  sedentary  life  will  require  and  eat  almost  as 
much  food  as  one  who  leads  a  very  active  life. 

Muscular  activity  as  play  or  work  increases  the  func- 
tions of  the  body.  More  blood  comes  to  the  skin  and 
more  blood  goes  away  from  the  skin  during  exercise. 
More  waste  products  are  thrown  off,  as  well  as  more 
heat .  The  same  thing  applies  to  every  part  of  the  body . 
The  brain,  for  instance,  gets  more  blood  during  physical 
activity  and  the  waste  products  are  much  better  re- 
moved. The  effects  of  exercise,  however,  are  particu- 
larly evident  in  the  lungs.  Rapid  breathing  means 
that  the  blood  is  circulating  around  at  a  much  greater 

94 


EXERCISE  AND  WORK  95 

rate  of  speed  and  thus  more  fresh  air  is  brought  to  the 
lungs  and  the  waste  products  driven  off.  As  a  result 
during  hard  work  there  is  a  beneficial  change  in  the 
lungs  and  in  the  heart  as  well. 

It  is  difficult  to  estimate  the  amount  of  work  which 
it  is  desirable  for  a  person  to  do,  but  a  certain  amount  of 
physical  exercise  is  absolutely  necessary  to  keep  the 
organs  of  the  body  in  good  condition.  A  fair  day's 
work  for  the  adult  man  may  be  represented  by  300 
foot  tons ;  a  hard  day's  work  by  400  foot  tons,  and  a 
very  hard  day's  work  by  500  foot  tons.  The  last, 
500  foot  tons,  is  the  amount  of  work  a  soldier  would 
perform  by  marching  twenty  miles  a  day  at  three  miles 
an  hour  on  a  level  road.  The  amount  of  work  would 
be  increased,  if  the  speed  were  greater.  A  man  weigh- 
ing 175  pounds,  carrying  twenty-five  pounds  up  six 
flights  of  stairs  (90  feet)  would  do  eight  foot  tons  of 
work.  All  these  estimates,  of  course,  are  entirely 
theoretical.  The  amount  of  work  necessary  to  keep 
the  man  of  sedentary  habits  in  good  condition  is  about 
100  to  150  foot  tons. 

The  problem  which  concerns  mental  workers  is  not 
that  of  the  day  laborer,  for  the  latter  gets  sufficient 
exercise  in  his  work.  The  problem  of  the  mental 
worker  is  to  get  sufficient  physical  exercise,  usually  as 
recreation,  to  keep  the  mind  and  body  at  its  maximum 
efficiency  in  addition  to  doing  his  ordinary  work. 
This  problem  gets  more  and  more  acute  as  he  gets 
older.  The  normal  child  gets  sufficient  amount  of 
exercise  in  his  play,  and  his  apparently  perpetual 
motion  is  a  perfectly  normal  thing.  As  he  grows,  the 
main  purpose  of  sports  is  to  furnish  the  requisite  amount 
of  exercise  which  is  necessary  for  the  well-being  of  any 
individual.  Soon,  there  is  apt  to  be  a  sharp  division 
between  the  athlete  and  the  non-athlete  and  this 
division  becomes  more  and  more  marked  with  a  tend- 


96 

ency  for  all  to  take  too  little  exercise.  It  is  a  fallacy 
to  think  that  sufficient  exercise  can  be  taken  once  a 
week,  or  once  a  month,  or  once  a  year.  In  order  to 
be  efficient  exercise  must  be  regular  and  at  relatively 
short  intervals. 

AH  exercise  should  tend  towards  using  all  of  the 
muscles  of  the  body.  But  just  as  muscular  exercise 
increases  the  blood  supply  to  the  brain  and  facilitates 
the  removal  of  the  waste  products,  so  exercise  of  one 
group  of  muscles  to  a  certain  extent  benefits  all.  If 
all  the  muscles  are  exercised,  however,  the  body  tends 
to  become  more  symmetrical  and,  in  the  second  place, 
it  is  much  better  for  the  muscles.  Walking  is  the 
favorite  form  of  exercise,  and  from  walking  or  running 
one  gets  beneficial  results  throughout  the  body. 

Another  question  arises  in  regard  to  exercise,  —  the 
matter  of  indoor  or  outdoor  work  or  play.  On  the 
Continent  the  people  favor  indoor  recreation,  and  in 
certain  countries  it  may  be  said  to  be  the  national 
method  of  taking  exercise.  In  this  country,  on  the 
contrary,  we  are  attached  to  outdoor  games  and  sports. 
The  condition  of  the  air  is  too  often  a  serious  objection 
to  gymnasium  work.  Another  objection  is  the  mo- 
notonous character  of  most  of  it,  as  it  lacks  any  recrea- 
tive features  at  all.  The  beneficial  results  of  exercise 
are  greatly  increased  if  the  person  enjoys  the  work  or 
play.  Competition,  within  reasonable  limits,  adds 
to  the  advantages  of  exercise,  largely  on  account  of 
the  increased  pleasure  and  the  training  of  the  mind 
and  nerves. 

Monotony  is  an  important  factor  in  the  causation  of 
fatigue,  and  all  recreative  exercise,  therefore,  should 
avoid  monotony.  Every  new  form  of  exercise  or  work, 
however,  relieves  the  monotony.  The  letter  carrier, 
for  instance,  may  find  sufficient  variety  in  riding  a  bi- 
cycle during  his  respites  from  walking,  although  such 


EXERCISE  AND  WORK  97 

a  slight  change  in  form  of  exercise  can  hardly  be  en- 
thusiastically recommended.  The  factor  of  fun  and 
the  variety  of  recreative  exercise  are  probably  of  more 
importance  than  the  mere  muscular  activity,  and  they 
illustrate  why  games  are  preferred  to  chest  weights. 

The  nervous  system,  rather  than  the  muscular 
system,  gives  out  when  exercise  is  too  prolonged  or 
too  vigorous.  But  the  nervous  system  can  be  made 
stronger  through  training.  In  fatigue,  for  instance,  a 
person  has  lost  control  over  his  muscles.  The  process 
of  getting  into  condition,  therefore,  is  directed  more 
towards  strengthening  the  nervous  system  in  its  con- 
trol over  the  muscles  rather  than  in  increasing  sheer 
muscular  strength. 

In  overtraining,  of  which  we  hear  so  much  in  con- 
nection with  athletic  contests,  it  is  the  nervous  system 
which  gives  out.  The  athlete's  muscles  and  strength 
are  the  same  after  becoming  overtrained  as  before. 
What  he  has  lost  is  the  quick  and  perfect  control  over 
his  muscles  and  strength.  Thus  overtraining  is  a 
mental  and  nervous  phenomenon  and  should  be  treated 
as  such.  The  overtrained  man  must  refresh  his 
nervous  system,  and,  if  he  is  really  overtrained,  he 
probably  cannot  **  get  back  into  shape  "  for  the  entire 
season  of  his  special  sport,  that  is  within  a  few  months. 

In  connection  with  athletics  we  hear  a  great  deal 
about  the  so-called  athletic  heart.  It  is  true  that  at 
times  of  hard  exercise,  a  great  deal  of  work  is  thrown 
upon  the  heart,  but  Nature  has  left  a  large  margin  of 
safety.  The  heart  will  respond  to  much  beyond  the 
accustomed  demands  without  injury.  It  is  possible, 
however,  for  a  person  who  is  in  a  flabby  condition  and 
who  has  done  little  physical  exercise  to  exert  himself 
to  such  an  extent  that  the  heart,  entirely  unaccustomed 
to  such  demands,  may  stretch.  If  a  man  is  well  trained, 
it  is  practically  impossible  for  him  permanently  to 


98  HEALTH  AND  DISEASE 

damage  his  heart.  Nature  is  kind  to  the  body.  Just 
when  a  person  is  going  to  injure  himself  by  overexer- 
tion,  he  faints  or  "passes  out,"  and  thus  it  is  impossible 
for  him  to  do  any  more  physical  work. 

Rowing  has  probably  been  more  frequently  accused 
of  damaging  the  heart  than  any  other  sport,  yet  in 
examinations  made  by  the  writer  on  men  who  have 
rowed  and  men  who  have  not,  no  evidence  has  been 
discovered  that,  under  a  proper  system  of  training,  any 
damage  is  done  to  the  heart.  The  heart  of  the  man 
who  had  rowed  for  ten  years  was  found  by  the  most 
careful  clinical  and  X-ray  test  to  be  practically  no 
larger  than  the  heart  of  the  man  who  had  not  rowed 
at  all.  All  the  evidence  seems  to  indicate  that  the 
term  "athletic  heart"  should  be  viewed  with  grave 
scepticism.  Sir  James  MacKenzie,  an  eminent  English 
authority  on  diseases  of  the  heart,  concludes :  "  I 
have  seen  a  very  large  number  of  youths  who  were 
supposed  to  be  unfit  to  play  games  or  to  row  because 
of  some  impairment  of  the  heart.  Except  in  a  few 
instances  of  manifest  heart  disease,  the  evidence  on 
which  the  heart's  impairment  was  based  was  those 
manifestations  of  murmurs  or  irregularity  which  my 
experience  has  shown  to  be  perfectly  consistent  with 
a  healthy  heart." 

With  our  modern  methods  of  precision  it  seems 
apparent  that  many  of  the  criteria  upon  which  diag- 
noses of  the  athletic  heart  were  made  were  false.  It  is 
extremely  doubtful  if  a  man  can  hurt  himself  physi- 
cally by  so-called  excessive  exercise,  although  he  may 
injure  himself  as  far  as  his  nervous  system  goes.  In 
this  connection  it  is  worthy  of  note  that  a  recent  Har- 
vard athlete,  who  made  his  letter  in  three  sports  and 
was  remarkably  proficient  in  all  and  who,  in  addition, 
held  the  college  strength  record,  had  a  heart  of  less 
than  the  average  size.  Statistics  on  the  relative 


EXERCISE  AND  WORK  99 

longevity  of  athletes  and  non-athletes  are  somewhat 
conflicting.  The  data  at  hand  indicate  strongly  that 
participation  in  strenuous  competitive  athletics  does 
not  shorten  life  and  that  premature  death  in  athletes 
is  to  be  attributed  to  the  same  factors  which  cause 
premature  death  in  the  non-athlete. 

There  is  a  habit  in  regard  to  exercise,  just  as  there  is 
a  habit  in  regard  to  everything  else.  Many  athletes 
stop  all  forms  of  exercise  as  soon  as  they  leave  college. 
This  is  extremely  unwise.  It  is  not  to  be  wondered 
at  that  the  bodily  mechanism  geared  up  to  a  high  state 
of  activity  rebels  and  chafes  at  a  sudden  change  to 
inactivity.  It  is  equally  unwise  for  the  man  who  has 
been  taking  no  exercise  to  go  out  and  exercise  a  great 
deal.  When  habits  are  being  changed,  they  should 
be  changed  gradually,  in  such  a  way  that  the  entire 
body  may  not  be  upset. 

Exercise  bears  an  important  relation  to  the  weight 
of  the  body.  If  an  individual  is  overweight,  exercise 
will  take  off  fat.  On  the  other  hand,  the  beneficial 
effects  of  exercise  are  such  that  the  blood  goes  to  all 
parts  of  the  body  and  more  waste  is  taken  away  so 
that  people  who  are  underweight  will  actually  gain  in 
weight.  As  a  matter  of  fact  people  who  are  normally 
active  physically  tend  to  approach  the  normal  standards 
of  weight. 

Some  of  the  evils  of  the  lack  of  exercise  are  familiar 
to  everyone.  In  contrast  to  the  fresh  complexion  and 
clear  eyes  of  the  man  who  is  "in  trim  "  are  the  poor 
color  and  sallow  complexion  of  the  man  who  takes  no 
exercise.  Lack  of  exercise  brings  as  one  punishment 
constipation  and  as  a  second  obesity,  unless  the  food 
intake  is  cut  down  to  the  low  requirements  of  the 
sedentary  life. 

The  proper  amount  of  exercise  to  take  and  particu- 
larly the  minimum  amount  of  exercise  which  one  should 


100  HEALTH  AND  DISEASE 

take  depends  a  great  deal  on  the  individual.  An  at- 
tainable minimum  for  the  average  adult  person  might 
well  consist  of  taking  simple  exercises  in  his  room  and 
to  get  out-of-doors  once  a  day  and  walk  rapidly  for  at 
least  hah*  an  hour.  In  addition,  it  is  desirable  for  any 
one  up  to  fifty  years  of  age  to  take  some  kind  of  mod- 
erately violent  exercise  at  least  once  a  week.  This 
should  be  sufficiently  strenuous  to  induce  perspiration. 
This  is  important  for  several  reasons.  In  the  first 
place,  there  is  an  old  saying,  which  happens  to  be  tru^, 
"  never  let  your  blood  vessels  get  stiff."  In  addition 
we  should  call  on  the  tremendous  reserve  which  Nature 
gives  to  us  at  least  once  in  a  while.  It  makes  little 
difference  what  kind  of  exercise  we  take,  so  long  as  we 
do  it  regularly. 

Fatigue.  While  exercise  is  beneficial,  there  are 
certain  evil  effects  of  excessive  exercise  and  excessive 
work.  As  in  the  case  of  the  first  Marathon  runner,  it 
is  possible  to  cause  immediate  death  by  overexertion, 
but  such  instances  are  extremely  rare.  The  effects  of 
overwork  or  overexercise,  that  is  excessive  fatigue,  are 
essentially  chronic  in  character  and  remote  in  point  of 
time.  Since  the  penalties  are  deferred,  it  is  often  pos- 
sible to  continue  the  fatigue-producing  activities  and 
to  permit  the  accumulation  of  fatigue  and,  conse- 
quently, the  accumulation  of  the  penalties. 

The  effect  of  physical  work  has  been  carefully  meas- 
ured in  the  physiological  laboratories  where  the  results 
of  work,  and  especially  the  result  of  very  violent  work, 
can  be  shown  in  the  blood.  Certain  poisons  are  given 
off  by  the  muscles  in  activity  which  are  carried  around 
by  the  blood,  so  that  we  feel  fatigue.  Fatigue  is 
Nature's  warning  and  we  should  heed  that  warning 
by  taking  a  rest.  If  violent  work  is  continued,  the 
blood  is  completely  filled  with  the  poisons  of  fatigue. 
These  poisons  go  to  all  parts  of  the  body  and  particu- 


EXERCISE  AND  WORK  101 

larly  to  the  nervous  system  and  the  brain.  That  the 
blood  contains  this  poison  of  fatigue  is  shown  by  ex- 
periments on  dogs.  A  dog  is  fatigued  by  exhaustive 
muscular  work.  Then  if  the  blood  of  the  tired  dog  is 
largely  exchanged  with  the  blood  of  a  fresh  dog,  the 
tired  dog  becomes  the  fresh  dog  and  the  fresh  dog  tired, 
although  he  has  done  no  work.  Similar  experiments 
have  been  carried  out  on  separate  muscles. 

Experiments  on  carrier  pigeons  have  shown  that, 
after  a  long  flight,  there  are  marked  changes  in  the 
brain  cells.  Thus  it  seems  that  the  trouble  caused  by 
fatigue  is  in  the  brain  cells  and  in  the  nervous  system. 
While  this  problem  of  fatigue  has  not  been  definitely 
settled,  it  seems  likely  that  the  evil  effects  of  fatigue 
are  much  more  in  the  nervous  system  than  in  the 
muscles  themselves.  Thus,  as  has  been  known  for  a 
long  time,  work  or  exercise  will  "  take  more  out  "  of 
the  individual  when  he  is  fatigued  than  when  he  is 
rested. 

These  principles  concerning  fatigue  should  be  ap- 
plied to  our  everyday  life.  We  should  not,  for  ex- 
ample, exercise  up  to  the  point  of  fatigue,  nor  when 
fatigued.  Neither  should  we  take  exercise  immedi- 
ately after  eating.  The  fact  that  a  stomach  is  upset 
after  a  race  or  after  violent  exercise  is  simply  another 
evidence  of  fatigue  and  its  results. 

Fatigue  plays  a  considerable  part  in  the  work  of 
daily  life.  This  subject  has  only  received  careful  con- 
sideration within  recent  years.  The  first  mutter- 
ings  on  the  relation  of  fatigue  to  industry  came  in 
England  about  1816,  when,  as  the  result  of  the  in- 
fluence of  medical  testimony,  laws  were  made  restricting 
the  hours  of  labor  in  certain  trades.  But  practi- 
cally all  our  knowledge  about  fatigue  comes  from  a 
later  date.  In  1907  a  Royal  Canadian  Commission 
was  appointed  to  investigate  the  conditions  governing 


102  HEALTH  AND  DISEASE 

the  work  of  the  telephone  workers  in  Toronto  and  the 
report  of  this  commission  made  a  tremendous  impres- 
sion on  the  industrial  world.  It  is  obvious  that  many 
other  factors  besides  the  actual  work  itself  demanded 
consideration  in  an  employment  so  complicated  as 
this.  Speed,  responsibility,  complexity  of  the  work, 
monotony,  as  well  as  the  factor  of  noise  and  confusion, 
were  shown  to  have  then*  share  in  the  production  of 
fatigue.  These  complicated  factors  obviously  involve 
the  nervous  system  from  their  very  nature.  The 
operators  were  found  to  suffer  from  specific  injuries  to 
the  special  senses  the  use  of  which  was  continuously 
required,  but  the  chief  injury  to  the  health  was  shown 
to  come  from  nervous  exhaustion.  As  a  result  of  its 
investigations,  the  Royal  Commission  found  that  seven 
hour's  work  as  a  telephone  operator  scattered  over  nine 
hours  was  a  sufficiently  long  working  day  for  women 
employed  in  this  nerve-racking  industry.  The  schedule 
was  framed  on  a  basis  of  good  working  conditions  and 
involved  a  schedule  of  two  hours'  work,  one  half  hour's 
relief,  one  and  one  half  hours'  work,  one  hour  inter- 
mission, two  hours'  work,  one  hah*  hour's  relief,  and  one 
and  one  half  hours'  work. 

Immediately  after  the  appearance  of  this  Canadian 
report,  valuable  statistics  from  Germany  came  to  light, 
which  showed  that  shorter  hours  instead  of  decreasing 
the  output  rather  tended  to  increase  it.  The  effect 
of  the  appearance  of  this  evidence  tended  to  offset 
some  of  the  consternation  among  employers  which 
had  been  caused  by  the  previous  report.  The  Zeiss 
Lens  Company,  of  Jena,  Germany,  in  1870  had  a 
twelve-hour  day  which  was  reduced  from  time  to  time 
on  humanitarian  grounds.  In  1900,  when  the  working 
hours  had  reached  the  eight-hour  level,  it  was  found 
that  the  men  actually  did  much  more  and  better  work 
than  under  a  nine-hour  day.  Abbe,  who  investigated 


EXERCISE  AND  WORK  103 

the  conditions  in  the  Zeiss  plant,  also  proved  that  one 
day  off  in  seven  increased  the  amount  of  work  done  and 
decreased  the  amount  of  fatigue.  His  conclusions  were 
that  the  eight-hour  day  benefited  both  the  employer 
and  the  employe.  Workers  during  the  first  year  of 
the  eight-hour  day  did  an  average  of  ten  days'  more 
work  than  under  the  nine-hour  system.  Instinctively 
the  workers  seemed  to  increase  their  intensity  of  ap- 
plication, and  in  place  of  being  constantly  subject  to 
lack  of  efficiency  through  an  accumulation  of  the 
effects  of  fatigue,  they  were  always  able  to  work  at 
their  best. 

There  is  a  considerable  temptation  to  make  broad 
generalizations  concerning  fatigue  and  efficiency,  but 
many  factors  complicate  the  deductions.  The  engineer 
of  a  fast  express  has  a  tremendous  strain  and  a  conse- 
quent amount  of  fatigue.  He  is  able  to  work  at  this 
tension  for  a  few  hours  and  may  even  be  better  for  a 
day's  rest  between  runs.  The  engineer  of  a  slow 
freight  may  be  able  to  work,  let  us  say,  eight  hours  a 
day,  without  damage  either  present  or  future.  The 
deciding  factors  of  fatigue  arising  from  work  are  the 
factors  of  speed,  responsibility,  complexity,  monotony, 
confusion,  and  noise,  rather  than  the  foot  pounds  of  ac- 
tual work  done.  Purely  creative  mental  work,  although 
requiring  no  output  of  physical  energy,  is,  perhaps,  the 
most  productive  of  fatigue.  The  output  of  genius  will 
not  be  increased  or  decreased  by  an  eight-hour  or  a  five- 
hour  workday.  So  every  job  must,  in  a  sense,  be  a  law 
unto  itself.  From  the  medical  viewpoint,  the  highest 
efficiency  in  output  and  health  in  the  average  job 
probably  demands  not  more  than  an  eight-hour  day 
for  men.  It  is  very  doubtful  whether  the  average 
woman  can  retain  her  health  (present  and  future)  and 
her  efficiency,  and  work  eight  hours  a  day  in  the  aver- 
age job  for  women  under  average  conditions  in  the 


104  HEALTH  AND  DISEASE 

shop  or  factory.  Women  who  are  actually  bearing 
children  need  rest  as  well  as  nourishment  for  two  in- 
stead of  one,  and  their  hours  of  work  should  be  regu- 
lated accordingly.  Children,  who  use  up  much  energy 
in  growing  and  whose  nervous  systems  are  more  deli- 
cate and  unstable  than  those  of  adults,  should  do  less 
work  than  women.  Children  under  fourteen,  and 
probably  under  sixteen,  should  have  no  regular  place 
in  the  industrial  world.  Child  labor  means  arrested 
development,  physical  and  mental,  and  chronic  fatigue, 
with  its  attendant  ills,  of  the  future  parents  of  the  race. 

It  is  unfortunate  but  true  that  we  have  no  adequate 
tests  for  determining  the  ability  of  a  given  individual 
to  undertake  a  given  task  without  damage.  Here  again 
we  are  brought  face  to  face  with  only  general  considera- 
tions. The  average  man  can  do  more  than  the  average 
woman,  who,  in  turn,  can  do  more  than  the  average 
child.  A  robust  person  will  probably  be  less  affected 
by  hard  work  than  a  delicate-appearing  person.  But 
that  is  all.  The  more  subtle  differences  in  persons, 
which  enable  one  to  accomplish  with  ease  and  without 
fatigue,  certain  tasks  that  are  impossible  for  another, 
are  not  yet  measurable.  What  we  have  learned  has 
been  from  the  accumulative  evidence  of  the  bitter 
experience  of  the  years  of  labor  of  many  people. 

As  people  have  different  degrees  of  resistance  to 
fatigue,  so  fatigue  affects  different  people  differently. 
It  affects  an  individual  in  his  so-called  weak  spots.  That 
is,  a  person  who  has  overworked  or  become  fatigued  may 
find  that  he  has  a  headache,  a  backache,  or  trouble  with 
his  eyes.  The  chances  are  that  he  has  always  had  this 
trouble  but  the  fatigue  has  aggravated  it  and  brought 
it  to  light. 

Fatigue  and  Accidents.  The  fact  that  fatigue  has 
a  marked  relation  to  accidents  and  disease  is  of  the 
utmost  importance  in  considering  this  subject,  both 


EXERCISE  AND  WORK 


105 


from  the  standpoint  of  industry  and  from  that  of 
everyday  life.  The  majority  of  accidents  in  industry 
happen  late  in  the  day  when  workers  are  tired.  It  is 
when  a  man  is  tired  that  he  does  not  get  his  hand  out 
of  the  way  of  a  mutilating  machine  which  he  may  have 
been  running  for  days,  weeks,  months,  or  even  years. 

The  following  German  statistics  show  the  number 
and  per  cent  of  accidents  during  one  year,  by  hour  of 
the  day : 


ACCIDENTS 

ACCIDENTS 

Hours 
Morning 

Number 

Per  cent 

Hours 

Number 

Per  cent 

6  to    7 

435 

2.82 

12  to  1 

587 

3.81 

7  to    8 

794 

5.16 

1  to  2 

745 

4.84 

8  to    9 

815 

5.29 

2  to  3 

1037 

6.73 

9  to  10 

1069 

6.94 

3  to  4 

1243 

8.07 

10  to  11 

1598 

10.37 

4  to  5 

1178 

7.65 

11  to  12 

1590 

10.31 

5  to  6 

1306 

8.48 

The  conclusion  from  these  figures  is  that  fatigue 
is  responsible  for  a  large  proportion  of  the  accidents  in 
the  industrial  world  and  that,  as  is  generally  recognized, 
it  is  wise  for  people  to  have  rest  periods.  The  curve, 
as  the  figures  show,  of  the  incidence  of  accidents  in  in- 
dustry is  low  in  the  early  morning  hours,  rises  rapidly 
in  the  last  hour  before  the  noon  rest.  The  curve  is  again 
low  in  the  early  afternoon  hours  and  again  rises  to  a 
very  high  point  just  before  the  end  of  the  working  day. 

The  tendency  in  modern  industry  is  to  have  a  worker 
do  only  one  thing.  This  results  in  the  worker  using 
only  one  series  of  nerves  and  muscles,  with  a  corre- 
sponding increase  in  the  amount  of  fatigue.  A  man 
working  in  this  way  should  have  more  frequent  and 
longer  rest  intervals  than  the  man  who  is  working  in 
a  less  specialized  way. 


106  HEALTH  AND  DISEASE 

A  bitter  controversy  has  arisen  over  this  question  of 
rest  intervals.  The  controversy  hangs  largely  on  the 
interpretation  of  that  slogan  of  the  modern  industrial 
world  —  efficiency.  It  is  usually  forgotten  that  the  late 
Mr.  Taylor,  whose  name  is,  perhaps,  most  widely  con- 
nected with  the  exploitation  of  the  so-called  efficiency 
systems,  advocated  much  more  than  the  use  of  stop- 
watches on  employes.  He  showed,  for  example,  that 
a  load  of  sand  was  more  rapidly  transferred  by  the  use 
of  a  certain  type  of  shovel.  Moreover,  it  made  a 
difference  in  time  whether  the  worker  began  at  the 
bottom  or  the  top  of  the  pile.  Such  considerations 
have  generally  been  accepted  as  sound.  Mr.  Taylor 
went  further  and  showed  that  certain  motions  enabled 
the  worker  to  wield  his  shovel  or  other  tool  more  effec- 
tively. If  only  these  motions  were  performed,  it  saved 
time  and  muscular  work.  But  Mr.  Taylor  and  all 
except  the  most  shortsighted  efficiency  engineers  ap- 
preciated that  the  increased  monotony  counterbalanced, 
in  part  at  least,  the  decrease  in  work.  The  time  saved 
could  be  utilized  in  frequent  rest  periods  and  the  output 
still  increased.  Many  employers  have  eagerly  ac- 
cepted certain  aspects  of  the  doctrine  of  efficiency,  but 
they  have  omitted  the  rest  periods.  Naturally  or- 
ganized labor  has  protested  vigorously.  Labor  further 
objects  that  the  complete  acceptance  of  this  doctrine 
tends  to  turn  human  labor  into  automatic  mechanical 
labor.  This  is,  of  course,  an  obvious  objection.  How- 
ever, it  should  be  apparent  that  increased  output  and 
efficient  work  depend  upon  identical  factors.  With 
increased  speed  and  monotony  come  increased  fatigue 
and  the  necessity  of  increased  rest  periods  to  nullify 
the  fatigue.  /-Fatigue  and  efficiency  are  contradictory 
terms.  An  efficient  workman  is  a  healthy,  fresh  work- 
man.^ A  few  farsighted  employers  are  beginning  to 
realize  that,  leaving  out  all  considerations  of  kindness 


EXERCISE  AND  WORK  107 

or  any  humanitarian  notion,  it  pays  in  increased  out- 
put to  arrange  work  so  that  the  employes  are  healthy, 
and,  certainly,  a  fatigued  workman  is  not  healthy. 

Another  count  in  the  indictment  against  fatigue  is 
that  it  creates  a  diminished  resistance  to  infections. 
There  is  a  greatly  increased  morbidity  among  the  over- 
fatigued,  especially  among  women  and  children.  One 
of  the  easiest  ways  of  getting  cold,  for  example,  is  the 
lowered  resistance  caused  by  fatigue.  Fatigue  also 
causes  an  individual  to  age  rapidly,  and  it  is  also  as- 
sociated with  various  nervous  manifestations.  Curi- 
ously enough  one  of  the  most  important  effects  of 
fatigue  is  to  create  an  inability  to  sleep. 

Sleep.  The  best  antidote  for  work  and  its  accom- 
panying fatigue  is  rest  and  the  best  form  of  rest  is  sleep. 
Sleep  is  a  somewhat  complicated  physiological  phe- 
nomenon to  which  we  should  devote  one-third  of  each 
twenty-four  hours.  But  just  as  is  the  case  with  work 
or  with  other  activities  the  amount  of  sleep  which  each 
individual  requires  varies  enormously.  Probably  more 
individuals,  in  early  adult  life  at  least,  require  more 
than  eight  hours  sleep  than  less  than  eight  hours.  Mr. 
Edison  is  said  to  need  only  four  hours  sleep  in  twenty- 
four  hours,  but  this  amount  of  sleep  would,  in  a  short 
time,  spell  ruin  to  the  physical  and  nervous  condition 
of  the  average  person.  Going  without  sleep  has  a 
greater  effect  upon  the  nervous  and  mental  states  than 
upon  the  physical.  Experiments  have  been  conducted 
in  which  people  were  kept  awake  for  a  long  time  — 
anywhere  from  three  to  ten  days.  The  usual  result  was 
that  after  about  three  days  the  subjects  would  actually 
go  to  sleep  with  their  eyes  open,  and  some  of  the  sub- 
jects would  develop  a  condition  closely  resembling 
acute  insanity.  This  condition  is  caused  by  fatigue. 
On  the  physical  side,  however,  the  immediate  effect  upon 
the  organs  and  on  the  heart  did  not  seem  to  be  marked. 


108  HEALTH  AND  DISEASE 

Many  people  —  General  Grant  was  an  instance  — 
take  their  sleep  wherever  opportunity  offers,  at  any 
time  during  the  day  or  night.  On  the  other  hand,  most 
of  us  are  governed  in  our  sleep,  in  our  method  of  sleep, 
and  in  our  time  of  sleep  by  habit.  If  we  do  not 
get  our  regular  amount  of  sleep,  we  tend  to  be  "  out 
of  sorts." 

There  are  other  ways  of  getting  rest  in  addition  to 
sleep.  A  person  may  get  rest  by  lying  down,  and  he 
also  gets  rest  even  if  it  seems  that  he  has  passed  a  sleep- 
less nigh^.  This  consideration  is  of  considerable  im- 
portance, for  it  shows  that  fatigue  can  be  lightened  by 
rest.  Furthermore,  the  idea  of  one  day  off  in  seven 
or  of  holidays  is  based  upon  this  conception. 

Recreation  is  also  closely  associated  with  the  subject 
of  rest  and  fatigue,  for  recreation  has  a  marked  effect 
on  fatigue.  The  amount  of  recreation  which  any  one 
individual  needs  is  entirely  a  personal  problem.  Each 
individual  presents  a  special  case.  AJ1  of  us  need  a 
considerable  diversity  of  occupation  —  a  diversity  of 
physical,  nervous,  and  mental  occupations.  Here  a 
number  of  emotional  factors  enter  into  consideration. 
If  we  like  to  do  a  thing,  we  do  it  easily  and  the  con- 
sequent fatigue  is  lessened.  There  is  such  a  thing  as 
joy  in  labor  and  getting  fun  out  of  a  task  which  makes 
work  a  form  of  recreation  and  markedly  decreases  the 
amount  of  fatigue. 

Sleeplessness  is  another  condition  associated  with 
fatigue,  for  overfatigue  is  one  of  the  principal  causes  of 
inability  to  sleep.  The  average  healthy  individual 
who  never  feels  fatigue  never  has  any  trouble  in  sleep- 
ing. But  when  we  are  overtired  we  tend  to  dream 
and  our  rest  is  broken.  The  cause  is  always  a  mental 
or  nervous  stimulus.  Of  course  there  are  physical 
stimuli  which  keep  us  awake,  but  they  are  temporary 
conditions  and  are  not  really  important  considerations 


EXERCISE  AND  WORK  109 

in  examining  the  problem  of  sleeplessness.  Coffee 
and  tea,  for  example,  in  the  case  of  a  large  number  of 
people,  are  a  cause  of  sleeplessness.  On  the  other 
hand,  there  are  people,  many  Scandinavians  for  ex- 
ample, who  go  to  sleep  after  drinking  a  large  bowl  of 
coffee.  Tobacco  may  also  cause  sleeplessness.  It  is 
a  common  occurrence  for  certain  individuals  so  to 
stimulate  themselves  by  interest  in  some  subject  that 
they  are  unable  to  compose  their  minds  and  nerves 
sufficiently  to  sleep. 

We  know  the  condition  where  people  do  not  sleep 
as  they  should  under  the  name  insomnia,  a  prevalent 
condition  in  modern  life,  which  is  due  to  the  effects 
of  fatigue.  The  treatment  for  this  condition  is  simple, 
for  it  is  only  a  question  of  developing  regular  and  good 
habits  of  sleeping.  The  use  of  drugs  or  sleeping 
powders  should  be  absolutely  prohibited  except  when 
taken  under  the  advice  of  a  physician.  It  should  be 
remembered  that  sleep  is  essentially  a  habit  and,  with 
the  variations  of  the  personal  equation,  the  sleep  habit 
is  formed,  interrupted,  and  broken,  just  as  any  other 
habit.  While  it  is  not  given  to  all  to  sleep  at  will,  still 
anyone  with  patience  and  persistence  can  acquire  good 
sleep  habits  without  resorting  to  artificial  means.  The 
converse  is  also  true,  for  poor  sleep  habits  can  also  be 
acquired.  As  is  the  case  with  any  habit,  regularity  is 
the  fundamental  factor. 

Dreams.  Sleep  is  not  a  fixed  state  and  it  is  some- 
times difficult  to  tell  whether  a  person  is  asleep  or  not. 
While  we  are  asleep  we  are  unconscious,  but  our  sub- 
conscious mind  is  constantly  busy  in  assorting  the  facts 
and  impressions  of  the  day.  Our  dreams  are  simply 
the  reaction  of  our  subconscious  mind,  expressions  in 
thoughts,  not  in  words,  to  the  impressions  which 
occurred  during  our  waking  hours.  Formerly  if  we 
wished  to  emphasize  the  unreality  and  improbability  of 


110  HEALTH  AND  DISEASE 

a  happening  or  of  an  idea,  the  stock  phrase  was  to  de- 
clare that  such  a  happening  or  such  an  idea  is  as  filmy  as 
a  dream,  or  made  of  such  stuff  as  dreams  are  made  of. 
The  brilliant  researches  of  Sigmund  Freud  and  of  Jung 
have  demonstrated  that  dreams  are  not  only  based  on  the 
actual  occurrences  of  life  or  of  thought,  but  often  reflect 
accurately  the  naked  realities  of  past  experiences  without 
the  confused  draperies  of  the  smothering  artificialities  of 
convention  and  of  pride.  While,  as  yet,  dream  analysis 
cannot  explain  reasonably  authentic  instances  of  the 
vivid  portrayal  of  events  happening  simultaneously  at 
great  distances,  yet  such  analysis  offers  a  simple  and 
logical  explanation  of  most  ordinary  dreams. 

The  dream  state  is  merely  twilight  and  is  most 
common  in  the  transition  between  sound  sleep  and 
wakefulness.  In  such  a  state  the  conscious  control  of 
the  thoughts  is  largely  lost.  While  we  may  designate 
this,  roughly,  as  the  subconscious  state,  locomotion, 
for  instance,  may  be  possible.  This  is  the  state  in 
hypnosis,  where  the  control  of  thoughts  and  actions 
becomes  delegated  to  another.  In  the  subconscious 
state  of  sleep  the  current  of  thoughts  flows  with  ex- 
traordinary rapidity,  yet  no  completely  new  thoughts 
or  ideas  occur.  All  thoughts  depend  upon  past  ex- 
periences, but  the  associations  and  sequence  of  the 
thoughts  in  the  dream  state  may  be  confused  and 
absurd.  On  waking  there  may  be  no  conscious 
recollections  of  the  experiences  of  the  dream.  As 
has  been  stated,  dreams  do  not  consist  of  words 
but  of  thoughts,  and,  furthermore,  dreams,  like 
thoughts,  are  not  confined  to  actual  material  happen- 
ings, for  the  mental  experiences  are  registered  just  as 
surely  as  are  material  happenings.  For  example,  the 
fear  that  some  one  may  be  drowned  is  registered  in  the 
mind  as  an  experience  of  the  past,  often  as  vividly  as 
an  actual  drowning  incident. 


EXERCISE  AND  WORK  111 

Everyone  dreams  and  all  sleep  is  accompanied  by 
dreams.  But  everyone  does  not  recall  the  dreams  on 
waking.  The  direction  which  dreams  take  is  often 
influenced  by  the  immediate  surroundings,  as,  when  it 
is  cold,  one  dreams  of  freezing.  Then  the  happenings 
of  the  day,  often  rehearsed  after  going  to  bed,  may 
determine  the  scene  of  the  dream.  A  constant  mental 
worry  is  the  classical  cause  of  dreams  as  is  seen  in  the 
terrors  of  the  conscience  stricken.  Even  the  lower 
animals  dream.  The  sleeping  dog  moves  his  legs  and 
half  yelps  in  his  dreams  of  the  chase. 

But  Freud  and  Jung  have  given  a  deeper  significance 
to  the  dream  state.  Freud  believed  that  in  dreams 
those  emotions  which  were  sternly  repressed  in  wak- 
ing hours  found  their  expression.  Sexual  emotions  in 
human  beings  are  repressed  both  by  law  and  custom. 
In  human  society  marriage,  which  permits  the  full 
expression  of  the  sexual  forces,  is  delayed,  for  most 
people,  until  well  after  the  development  of  the  sexual 
instinct  and  is  denied  to  others.  Such  individuals, 
however,  are  not  bereft  of  the  emotions  of  sex.  Freud, 
in  particular,  believed  that  in  the  dream  state  such 
emotions  are  dominant.  As  a  result  of  this  conclusion 
he  built  up  an  array  of  symbolic  formulas  by  which 
no  dream  can  be  interpreted  on  other  than  a  sexual 
basis.  He  believed,  furthermore,  that  in  the  dream 
analysis  which  showed  the  repression  of  the  sex  emo- 
tions, he  had  the  clue  to  the  nervous  states  of  many 
individuals.  While  all  must  credit  Freud  with  an 
important  share  in  the  elucidation  of  a  confused  sub- 
ject, there  is  a  feeling  that  he  overemphasized  the  sex 
element.  But  his  work  and  that  of  his  followers  have 
shown  us  that  dreams  are  merely  records,  perhaps 
disjointed,  but  still  records  of  past  experiences,  and 
we  now  know  the  parallelism  of  the  dream  and  other 
subconscious  states.  We  are  certain  that  events  and 


HEALTH  AND  DISEASE 

thoughts  are  recorded  permanently  in  the  wonderful 
registry  of  the  mind  and  never  lost.  While  an  event 
may  be  forgotten  in  the  conscious  state,  that  event 
may  be  recalled  in  the  dream  state,  the  hypnotic  state, 
or  in  other  subconscious  states. 

The  importance  of  all  this  may  be  illustrated  by  a 
single  example.  A  person  is  always  much  upset  by 
the  fear  of  being  alone  in  a  closed  place.  This  idea  is 
fixed,  an  obsession.  It  interferes  with  the  person's 
life,  activity,  health,  and  happiness.  The  dreams 
nearly  always  concern  some  frightful  experiences  as- 
sociated with  being  confined  in  dark  dungeons  or  the 
like.  Sleep,  with  the  almost  inevitable  dream,  is 
feared.  In  the  hypnotic  state  it  is  elicited  that  as  a 
child  the  subject  was  punished  by  being  shut  up  in  a 
closet  and  forgotten  for  hours,  to  the  abject  terror  of 
the  child.  In  the  conscious  state  the  incident  is  en- 
tirely forgotten,  but  it  had  made  so  deep  an  impression 
on  the  mental  register  that  it  served  as  the  basis  for 
the  subconscious  mental  activities. 

Thus  dreams,  for  the  most  part,  can  be  explained. 
While  their  interpretation  is  by  no  means  an  exact 
science,  most  of  us  can  find  the  basis  of  our  dream  in 
our  past  experiences,  either  as  records  of  material  fact, 
or,  sometimes,  as  the  startling  records  of  thoughts,  as- 
pirations, and  emotions  which,  perhaps,  we  fondly 
imagined  we  never  allowed  ourselves  to  entertain. 


CHAPTER  VI 

ALCOHOL,  TOBACCO,  AND  THE  HABIT-FORMING  DRUGS 

Alcohol 

THE  controversy  which  rages  over  the  subject  of 
alcohol  is  so  great  and  is  waged  with  such  bitterness 
that  it  has  well  given  rise  to  the  remark  that  alcohol 
is  equally  inflammable  whether  one  touches  a  match 
to  it  or  writes  about  it.  Writers  who  have  been  so 
indiscreet  as  to  endeavor  to  present  the  scientific 
knowledge  on  the  subject  have  been  bitterly  assailed 
by  the  protagonists  of  one  side  or  the  other  of  the 
controversy,  and  their  conclusions,  based  on  scien- 
tific data  and  experience,  have  been  outrageously 
condemned.  Strange  as  it  may  seem,  concerning  a 
subject  which  has  been  the  subject  of  debate  since 
the  beginnings  of  history,  there  has  been,  until  re- 
cently, little  available  scientific  information  and  few 
statistics  concerning  the  use  and  abuse  of  alcohol. 
Even  now,  comparative  statistics  are  in  such  a  form 
as  to  be  of  little  real  value,  and  we  can  scarcely  hope 
to  make  any  definite  progress  toward  a  final  solution  of 
this  problem  until  we  attack  it  without  prejudice  and 
systematize  the  knowledge  which  we  have  at  hand. 

The  general  opinion  seems  to  be  that  more  alcohol  is 
being  consumed  at  the  present  time  than  at  any  other 
period  in  history.  This  does  not  mean,  however,  that 
there  is  more  drunkenness,  for,  in  point  of  fact,  there  is 
considerable  evidence  that  there  is  less  drunkenness 
and  less  abuse  of  alcohol  than  ever  before.  But  on 

113 


114  HEALTH  AND  DISEASE 

account  of  the  increased  means  of  transportation  and 
on  account  of  the  fact  that  the  alcohol  trade  is  always 
highly  profitable,  there  is,  at  the  present  day,  practically 
no  alcohol -free  people  in  the  world.  This  world- wide 
alcohol  problem  cannot  be  discussed  from  any  isolated 
point  of  view,  for  it  is  a  problem  of  nutrition,  of  hygiene, 
of  the  individual,  and  of  the  community.  The  ques- 
tion must  be  considered  in  its  economic  relation  as  well 
as  in  its  relation  to  hygiene. 

Alcohol  as  a  Food.  From  a  strictly  scientific  basis, 
alcohol  must  be  regarded  as  a  food,  for  when  a  gram  of 
alcohol  is  burnt  seven  calories  of  heat  are  given  off. 
Alcohol,  however,  is  not  a  tissue-builder,  but  a  fuel. 
It  has  been  proved  that  alcohol,  in  the  absence  of  suf- 
ficient fats  or  carbohydrates,  can  be  utilized  in  the  body 
as  a  fuel  food,  but  this  use  is  limited  and  is  restricted 
to  about  two  ounces  of  alcohol  daily.  Two  ounces  of 
alcohol  means  about  four  ounces  of  whiskey  —  two  or 
three  ordinary  drinks  —  or  two  and  a  half  pints  of  five 
per  cent  beer.  More  than  this  amount  is  not  commonly 
used  in  the  body,  but  may  be,  and  often  is,  stored  up 
as  fat.  Since  we  have  carbohydrates  and  fats,  which 
must  be  taken  in  addition  to  supply  the  needed  calories, 
it  is  evident  that  alcohol  is  of  negligible  importance  as  a 
food.  Only  in  the  occasional  treatment  of  diabetes,  dur- 
ing a  starvation  period  or  while  the  carbohydrates  must 
be  reduced  to  a  very  low  point  and  the  use  of  an  excess 
of  fats  may  be  harmful,  can  the  use  of  alcohol  as  a  food 
be  considered  of  the  slightest  real  importance. 

Alcohol  as  a  Medicine.  Life  is  in  nowise  dependent 
on  alcohol  and  there  is  no  controversy  about  the  fact 
that  a  healthy  person  can  live  without  it.  But  when 
we  come  to  the  consideration  of  the  value  of  alcohol 
in  disease,  we  encounter  a  wide  diversity  of  opinion. 
There  is  no  scientific  evidence  that  alcohol  is  a  stimulant 
in  disease,  despite  the  superstitions  concerning  its 


ALCOHOL  115 

wonderful  stimulating  qualities,  although  it  may 
possibly  be  the  case  that  the  stimulating  effect  of  al- 
cohol cannot  be  tested  by  our  present  methods  of 
estimating  stimulation.  The  wide  clinical  experience 
of  some  of  the  wisest  physicians,  of  whom  Dr.  Abraham 
Jacobi,  of  New  York,  is  a  leader,  has  convinced  them 
of  the  value  of  alcohol  in  certain  septic  conditions,  as 
pneumonia  and  diphtheria.  Yet  it  is  a  fact  that  our 
best  hospitals  to-day  use  only  a  fraction  of  the  amount 
of  alcohol  which  they  thought  so  essential  a  generation 
ago.  Many  physicians  successfully  treat  sepsis  without 
alcohol,  and  to  the  mind  of  the  writer  the  experience 
at  the  bedside  coincides  with  the  scientific  data  that 
alcohol  is-  not  a  stimulant  in  disease. 

Little  need  be  said  concerning  the  common  habit  of 
carrying  a  flask  of  strong  spirits  against  a  possible 
emergency,  —  which  is  stretched  to  cover  anything 
from  fainting  to  tedium.  Let  a  person  be  hurt  in  the 
street  and  there  are  always  several  volunteer  amateur 
administrators  of  first  aid  who  force  brandy  or  whiskey 
down  the  throat  of  the  afflicted.  The  only  certain 
result  from  this  procedure  is  the  confusion  of  the 
surgeon,  who  often  finds  it  extremely  difficult  to  differ- 
entiate between  the  stupor  of  drunkenness  and  the 
stupor  of  injury.  Alcohol  is  an  irritating,  highly 
volatile,  quickly  diffusible  liquid  and  the  beneficial 
effects  in  restoring  consciousness  after  fainting  are 
quite  similar  to  those  of  other  fluids,  as  solutions  of 
ammonia,  the  aromatic  spirits  for  example.  Alcohol 
does  relax  the  small  peripheral  blood  vessels,  but  so  do 
other  substances  and,  anyway,  loss  of  consciousness  is 
only  a  symptom  and  of  itself  a  harmless  symptom. 
It  must  be  admitted  that  the  use  of  alcohol,  while, 
perhaps,  somewhat  beneficial,  is  not  important,  cer- 
tainly not  essential,  and  can  be  replaced  by  other  less 
harmful  substances. 


116  HEALTH  AND  DISEASE 

Since  alcohol  has  the  physiological  property  of  ex- 
citing a  fictitious  sense  of  well  being,  it  has  been  widely 
used  in  medical  practice  in  the  treatment  of  elderly 
persons  and  certain  invalids,  particularly  convalescents, 
upon  whom  life  bears  heavily.  Alcohol  is  used  in  such 
cases  for  its  physiological  effect  of  partially  numbing  the 
sensibilities  and  creating  an  artificial  euphoria.  It  is 
not  used  as  a  stimulant  or  as  a  food.  In  such  situations 
the  use  of  alcohol  often  seems  desirable,  but  it  is  not 
indispensable,  nor  is  it  entirely  void  of  danger. 

The  Immediate  Physiological  Effect  of  Alcohol. 
The  intricacies  of  the  scientific  work  on  this  subject 
are  tremendous,  but  in  a  general  discussion  of  the 
problem  it  may  be  divided  into  two  headings :  the 
use  of  small  amounts  of  alcohol,  and  the  use  of  large 
amounts,  or  an  excess,  of  alcohol.  Most  of  us  are 
familiar,  through  experience  or  observation,  with  the 
immediate  physiological  effect  of  alcohol.  After  a 
single  drink  there  is  a  sense  of  increased  comfort  and 
well  being.  The  discomforts  of  the  body  and  the 
worries  of  the  mind  are  less  oppressive.  There  is  an 
apparent  quickening  of  the  action  of  the  mind  and 
body.  We  feel  that  our  phrases  are  better  turned  and 
our  actions  better  timed.  But  innumerable  experi- 
ments have  shown  that,  while  the  subject  was  con- 
vinced that  after  alcohol  he  performed  such  tests  as 
touching  differently  numbered  buttons  at  the  word  of 
command  with  more  speed  and  accuracy  than  before 
taking  alcohol,  as  a  matter  of  record  his  performance 
after  alcohol  was  slower  and  less  accurate.  A  large 
number  of  similar  tests  of  speed  and  precision  could  be 
quoted,  all  showing  that  the  effect  of  alcohol  is  to 
diminish  the  efficiency  of  any  act  requiring  even  the 
simplest  coordinated  activity  of  mind  and  nerve  im- 
pulse. The  amount  of  alcohol  used  in  all  these  ex- 
periments was  small,  so  small  that  the  subjects  and 


ALCOHOL  117 

the  observers  were  often  not  conscious  of  any  abnor- 
mality of  appearance  or  behavior.  We  need  go  no 
further  in  order  to  draw  the  only  and  obvious  deduc- 
tion —  that  alcohol  and  work  do  not  go  together. 
Better  work  after  alcohol  is  purely  a  fictitious  belief. 
Of  course  the  isolated  exception,  which  does  not  need 
serious  consideration,  may  also  show  that  the  numbing 
effect  of  alcohol  on  the  abnormal  and  incapacitating 
sense  of  apprehension  and  diffidence  may  counteract 
the  harmful  effects  and  thus,  occasionally,  result  in  a 
better  speech  or  a  better  contest. 

The  effects  of  large  and  excessive  doses  of  alcohol 
are  only  too  familiar.  In  large  doses  alcohol  acts  like 
ether  or  chloroform.  There  is  the  preliminary  stage 
of  excitement,  mental  confusion,  and,  often,  excessive, 
incoordinated  activity,  followed  by  the  characteristic 
stage  of  stupor  and  loss  of  consciousness.  The  penalty 
to  the  health  in  the  consumption  of  alcohol,  even  in 
large  amounts,  once  or  even  sporadically,  is  in  itself 
probably  slight  and  perhaps  comparable  to  the  single 
or  occasionally  repeated  use  of  ether  as  a  surgical 
anesthetic.  But  in  the  case  of  alcohol  there  are  defi- 
nite associated  dangers.  Accidents  are  frequent  at 
times  of  alcoholic  excitement  and  overactivity.  Ex- 
posure to  the  physical  elements  and,  of  much  greater 
importance,  exposure  to  venereal  and  other  infections 
are  extremely  common  during  alcoholic  excess.  There 
is  a  definite  relation  between  alcohol  and  venereal 
disease,  —  in  fact,  this  is  one  of  the  strongest  indict- 
ments against  alcohol.  Furthermore,  the  excessive 
activity  so  frequently  generated  by  alcohol  produces 
fatigue,  although  the  individual  may  not  be  conscious 
of  fatigue  during  its  production,  but  usually  painfully 
so  afterwards.  A  further  associated  damage  is  caused 
by  the  irritating  effects  of  the  alcohol  on  the  digestive 
tract,  which  so  often  causes  the  stomach  to  rebel. 


118  HEALTH  AND  DISEASE 

This  insult  and  other  insults  to  the  orderly  bodily  func- 
tions may  or  may  not  be  lightly  tolerated  by  the 
human  mechanism. 

The  Remote  Physiological  Effects  of  Alcohol.  This 
implies  a  continuous  use  of  alcohol.  In  the  European 
countries,  perhaps  more  notably  before  the  war,  alcohol 
was  used  in  some  form  by  a  large  proportion  of  the 
inhabitants.  Italy,  for  example,  heads  the  list  in  the 
consumption  of  alcohol,  yet  the  Italians  in  their  home 
country  are  a  sober  people.  Drunkenness  is  not  com- 
mon. The  people  use  alcohol  moderately  and  do  not 
abuse  it  in  the  ordinary  sense.  The  Italians  and  the 
French  drink  with  their  meals  and,  in  the  evening,  their 
light  wines  with  their  low  alcoholic  content.  The 
Teutonic  races  do  likewise  with  their  light  wines  and 
beers.  Presumably  the  total  daily  consumption  of 
alcohol  frequently  exceeds  two  ounces  of  pure  alcohol, 
although  the  total  amount  is  small.  The  problem  at 
issue  is,  granted  that  the  consumption  of  even  the 
smallest  amount  of  alcohol  hampers  work  and  that 
alcohol  has  no  place  during  industrial  activity,  does 
the  consumption  of  this  amount  of  alcohol,  habitually 
taken,  never  to  excess,  do  the  individual  harm?  We 
cannot  answer  this  question.  The  evidence  of  all 
sorts  at  hand,  longevity  and  morbidity  statistics  and 
the  like,  fails  to  show  that  such  consumption  of  small 
amounts  of  alcohol  outside  of  working  hours  does 
the  individual  any  harm.  On  the  other  hand,  this 
consumption  of  alcohol  does  no  good.  Furthermore, 
no  individual  can  be  certain  that  his  temperament 
and  his  environment  may  not  conspire  to  increase 
the  amount  of  alcohol  consumed,  so  that  he  may 
acquire  the  alcohol  habit  and  become  a  chronic 
alcoholic.  While  most  such  drinkers  of  light  wines 
and  beers  do  not  change  their  habits,  there  are  those 
who  do. 


ALCOHOL  119 

The  Alcohol  Habit.  Among  bad  habits,  the  alcohol 
habit  easily  ranks  first  in  importance.  The  artificial 
euphoria  so  easily  induced  by  alcohol  brings  temporary 
solace  and  comfort  from  the  nagging  troubles  of  mind 
and  body.  Many  persons,  however,  seek  this  euphoria 
without  any  excuse.  Others  drift  into  the  alcohol 
habit  through  various  accidents  of  environment. 
The  individuals  who  easily  form  habits  comprise  a 
distinct  group.  A  somewhat  unstable  nervous  system 
a.nd  a  deficient  self  control  are  characteristic.  It  may 
well  be  that  if  this  group  did  not  have  the  alcohol  habit, 
some  other  habit,  equally  bad  or  worse,  might  be 
substituted.  But  in  addition  to  these  persons  of  un- 
stable mentality,  strong-minded  men  and  women  who 
know  all  the  evils  of  alcohol  become  enslaved  to  its  use. 
Once  the  habit  is  formed,  only  the  minority  escape 
permanently.  There  are  varying  degrees  in  the  alcohol 
habit,  of  which  the  advanced  type  is  the  most  familiar. 
As  a  matter  of  fact  the  less  advanced  type  is  more 
common ;  the  man  who  is  never  drunk,  attends  to  his 
business,  but  who  is  only  too  well  aware  of  the  misery 
without  his  drink,  and  who  is  equally  aware  of  the 
deterioration  through  drink  and  the  dangers  just 
ahead.  He  has  sufficient  self  control  to  keep  himself 
in  hand  as  he  says  (which  only  means  to  keep  his 
alcohol  down  to  its  lowest  possible  amount),  but  he 
would  stop  if  he  could. 

In  the  alcoholic  habit  lies  the  greatest  danger  in  the 
use  of  alcohol,  for  this  always  means  chronic  alcoholic 
excess  and  such  an  excess  always  means  disease.  As 
Koren l  has  recently  pointed  out,  the  dangers  of 
alcoholic  excess  and  of  the  alcohol  habit  lie  mainly  in 
the  concentrated  forms  of  alcohol  and  not  so  much  in 
the  light  wines  and  beers.  On  the  other  hand,  it  can 

1  Koren,  "  Alcohol  and  Society,"  New  York,  1916. 


120  HEALTH  AND  DISEASE 

be  urged  with  some  justice  that  the  path  to  the  stronger 
alcoholic  drinks  often  leads  from  the  use  of  the  lighter 
drinks. 

Alcoholic  Excess.  There  is,  and  probably  never  will 
be,  no  agreement  as  to  what  constitutes  alcoholic 
excess.  For  one  man  a  single  drink  is  excess,  while 
another  seems  unaffected  by  the  daily  consumption 
of  considerable  alcohol.  Although  the  amount  of 
alcohol  which  can  be  burnt,  namely  two  ounces,  may 
in  general  be  taken  as  the  dividing  line,  the  usual  and 
a  good  working  conception  of  alcoholic  excess  means 
the  daily  consumption  of  at  least  twice  that  amount. 

Those  who  habitually  use  alcohol  to  excess  divide 
themselves,  roughly,  into  three  groups.  In  the  first 
group  we  have  the  actual  social  drunkard,  perhaps  the 
most  common  type.  He  rarely,  if  ever,  drinks  alone. 
With  him  drinking  is  largely  a  matter  of  environment, 
yet  he  tends,  but  not  inevitably,  to  increase  his  con- 
sumption of  alcohol  and  alcohol  often  "  gets  him." 
Such  a  type  is  usually  easily  cured  by  the  elimination 
of  alcohol  and  a  change  in  the  environment. 

In  the  second  group  comes  the  steady  tippler  upon 
whom  the  habit  has  its  firmest  hold.  He  —  many  of 
them  are  women  —  drinks  whenever  the  craving  calls. 
He  is  not  so  often  drunk  as  the  social  drunkard,  but, 
in  the  end,  he  rarely  goes  to  bed  in  a  condition  even 
approaching  sobriety.  He  is  the  type  who  has  to 
start  the  day  with  a  drink  to  steady  his  nerves  and 
settle  his  stomach.  His  is  the  alcohol  habit  and  this 
is  the  hardest  type  to  break. 

The  third  type  goes  under  the  name  of  dipsomania. 
We  have  a  feeling  that  this  term  is  mainly  used  as  a 
convenient  excuse  for  irregular  behavior.  It  is  true, 
however,  that  there  are  certain  individuals  who  are 
afflicted  with  this,  and  it  is  probable  that  their  de- 
ficiencies are  temperamental.  The  so-called  dipso- 


ALCOHOL  121 

maniac  is  the  person  who  goes  without  alcohol  for 
weeks  and  months,  and  then  goes  on  a  terrific  spree. 
Apparently  all  the  cures  in  the  world  do  not  affect 
him.  Once  started  on  a  spree,  he  will  drink  and  drink, 
pawn  his  clothes,  sleep  in  the  gutter,  and  still  continue 
drinking  as  long  as  he  can  get  anything  to  drink. 

Alcohol  and  Disease.  Chronic  alcoholic  excess 
leads  to  physical,  mental,  and  moral  deterioration, 
effects  with  which  we  are  all  familiar.  The  finer  sensi- 
bilities are  the  first  to  go.  The  primitive  emotions, 
however,  persist  and  become  dominant,  as  instanced 
by  the  fear  of  the  alcoholic  in  delirium  tremens.  So,  too, 
the  reformation  of  the  chronic  alcoholic  —  the  cessa- 
tion of  alcohol  —  leaves  the  victim  with  a  deteriorated 
body  and  mind.  The  body  is  often  easily  built  up,  but 
the  reconstruction  of  the  mind  is  more  difficult  and 
sometimes  impossible.  It  is  this  situation,  in  the 
period  before  complete  mental  reconstruction,  that 
favors  relapse.  Alcohol  is  peculiarly  a  nerve  poison. 
So  there  are  cases  of  typical  alcoholic  neuritis,  while 
cases  of  alcoholic  insanity  are  both  numerous  and  com- 
mon. About  twelve  per  cent  of  the  admissions  into 
hospitals  for  the  insane  are  diagnosed  as  alcoholic 
insanity.  A  large  proportion  of  these  cases  regain 
their  sanity. 

Alcohol  causes  many  disturbances  of  the  body  that 
are  purely  physical.  The  "  gin  drinker's  liver  "  (one 
form  of  cirrhosis  of  the  liver)  is  directly  associated  with 
alcoholic  excess.  However,  many  of  these  disturbances 
which  are  commonly  ascribed  to  alcohol  are  only  in- 
directly caused  by  it.  It  is  often  not  so  much  the  al- 
cohol itself  as  the  contributory  effects  or  the  effect  of 
certain  conditions  induced  by  alcohol.  The  contribu- 
tory effect  of  alcohol  is  well  illustrated  by  the  high  death 
rate  of  alcoholics  who  have  infectious  diseases.  Pneu- 
monia in  a  chronic  alcoholic  is,  perhaps,  not  invariably 


122  HEALTH  AND  DISEASE 

fatal,  but  nearly  so.  Then,  too,  alcoholics  acquire  in- 
fectious diseases  more  readily  than  healthy  persons. 
As  shown  by  the  insurance  statistics  the  alcoholic  has 
definitely  lowered  his  expectancy  of  life.  Alcohol  is 
accused  of  being  an  important  factor  in  the  production 
of  arterio-sclerosis  and  other  degenerative  processes. 
Since  degeneration  is  often  the  end  result  of  wear  and 
tear,  we  hardly  need  alcohol  to  explain  early  senility 
in  the  alcoholic,  who,  on  account  of  his  alcohol,  has 
been  abusing  the  human  machine  by  irregular  habits 
of  eating  and  sleeping,  and  by  exposure  to  accidents 
and  disease,  particularly  to  the  venereal  diseases,  of 
which  syphilis  is  in  itself  a  direct  cause  of  arterio- 
sclerosis. If  we  add  the  factor  of  poverty,  insufficient 
food  and  shelter  which  so  commonly  follows  in  the 
wake  of  alcoholism,  we  have  an  easy  explanation  of  the 
early  wearing  out  and  wastage  of  the  bodily  machine 
of  the  alcoholic. 

Alcohol  and  Posterity.  Alcoholism  limits  the  off- 
spring, but  chiefly  through  associated  conditions.  In 
animals  alcohol  itself  diminishes  the  number  of  inferior 
offspring.  Since  the  alcoholic  is  essentially  physically 
deteriorated,  the  alcoholic  mother  gives  her  children 
a  poor  beginning  in  life.  It  is  doubtful,  however, 
whether  alcoholic  tendencies  are  inherited,  for  the 
development  of  tendencies  to  alcoholism  are  probably 
due  to  the  environment.  Furthermore,  the  inferior 
offspring  of  alcoholic  parents  can  trace  their  inferiority 
to  the  associates  of  alcohol,  rather  than  to  the  alcohol 
itself. 

Alcohol  and  Crime.  Many  crimes  are  committed 
under  the  influence  of  alcohol,  for  many  criminals 
drink  to  excess.  But  it  does  not  follow  that  alcohol 
is  intimately  related  to  crime.  The  criminal,  often 
a  defective,  demonstrates  his  inferiority  both  by  his 
criminal  instincts  and  his  alcoholism. 


ALCOHOL  123 

Alcohol  and  Poverty.  Alcohol  is  only  too  frequently 
the  cause  of  poverty  and  much  economic  waste.  The 
attendant  want  and  misery  is  enormous.  Neverthe- 
less alcohol  is  not  the  sole  cause  of  poverty,  for  poverty 
would  exist  even  without  alcohol.  It  must  be  ac- 
cepted, however,  that  without  alcohol  there  would  be 
less  poverty. 

The  Solution  of  the  Alcohol  Problem.  It  is  generally 
believed  that  the  alcohol  problem  has  in  no  way  been 
satisfactorily  solved.  On  the  whole,  legislation  against 
drink  has  failed  to  do  what  was  expected  of  it.  All 
parties  are  agreed  that  there  are  harmful  results  con- 
nected with  the  use  of  alcohol.  All  are  agreed  that 
most  of  the  harmful  effects  of  alcohol  arise  from  the 
use  of  drinks  with  a  high  percentage  of  alcohol.  All 
admit  the  danger  of  acquiring  the  alcohol  habit,  par- 
ticularly if  strong  drinks  are  used.  The  drinking  of 
alcohol  on  an  empty  stomach,  as  in  the  American  cock- 
tail habit,  and  the  taking  of  "  bracers  "  at  any  time 
and  especially  at  all  regularly,  are  sources  not  only 
of  danger  but  also  of  actual  damage.  No  one  believes 
that  drunkenness  is  anything  but  an  evil.  All  are 
agreed  that  there  should  be  an  increase  of  knowledge 
concerning  the  evil  effects  of  alcoholic  excess.  While 
there  are  many  proposed  solutions  of  the  problem 
presented  by  the  conditions,  perhaps  the  two  most 
important  may  be  briefly  discussed  here. 

Any  proposed  solution  of  the  alcohol  problem  de- 
pends upon  the  viewpoint.  From  the  personal  point 
of  view  of  the  individual  it  is  often  argued  that  the 
occasional  use  of  a  small  amount  of  alcohol,  preferably 
in  the  form  of  light  wines  and  beers,  at  times  which 
do  not  conflict  with  work,  probably  does  no  harm. 
The  experience  in  Europe,  particularly  in  Italy,  is 
cited  to  substantiate  this  view.  It  is  granted  that 
abuse  of  alcohol  is  bad  and  that  a  few  exceptional 


124  HEALTH  AND  DISEASE 

individuals  should  never  drink.  The  arguers  for  this 
viewpoint  believe  that  since  harm  conies  from  alcoholic 
excess,  a  more  intelligent  realization  of  the  dangers  of 
excess  will  result  in  a  decrease  in  the  abuse  of  alcohol. 
From  this  viewpoint  remedial  legislation  is  suggested 
by  Koren  and  others,  based  upon  a  careful  investiga- 
tion of  the  Gothenburg  and  other  systems,  which 
practically  legislate  the  strong  alcoholic  drinks  out  of 
existence  by  excessive  taxation  and  which  bring  the 
alcohol  traffic  under  adequate  control. 

From  the  broader  viewpoint  of  the  community 
interest  in  this  economic  and  social  problem,  the  more 
radical  solution  of  complete  suppression  or  prohibition 
is  suggested.  It  is  pointed  out  that  alcohol  is  not 
absolutely  essential  as  a  food  or  as  a  medicinal  remedy. 
A  knowledge  of  the  dangers  of  alcohol  does  not  prevent 
educated  people  (doctors,  for  example)  from  falling  a 
prey  to  its  ravages.  Furthermore,  alcohol  is  a  habit- 
forming  poison.  Hence,  in  view  of  its  harmful  effects 
and  since  it  adds  nothing  that  is  essential  to  human 
life,  many  people  would  prohibit  its  manufacture  and 
use  as  a  beverage. 

Certainly  it  seems  that  the  logic  is  with  the  latter 
view.  Unenforced  prohibition,  however,  leads  to 
the  worst  evils  of  alcoholism,  —  secret  tippling,  vile 
products,  and  concentrated  forms  of  alcohol.  More- 
over, alcohol  is  so  readily  produced  by  fermentation 
and  distillation  that  prohibition  is  difficult  of  enforce- 
ment. Prohibition  will  be  enforced  and  will  prohibit 
alcohol  only  with  the  genuine  backing  of  the  com- 
munity. Recent  years  have  seen  a  worldwide  move- 
ment in  favor  of  prohibition.  The  European  War 
created  a  situation  in  which  almost  despotic  power 
enabled  England,  Russia,  and  France  to  enact  drastic 
laws  that  otherwise  might  have  only  resulted  after 
years  of  discussion.  But  the  movement  began  long 


TOBACCO  125 

before  the  war.  It  began  with  the  accumulation  of 
the  evidence  of  the  evils  of  drink  and  of  the  economic 
waste,  particularly  of  individual  efficiency,  caused  by 
alcohol.  Whether  the  liquor  regulations  in  Europe 
can  continue  after  the  war  depends  on  the  support 
given  the  legislation  by  the  several  peoples.  For  drink- 
laws,  either  in  Europe  or  America  —  and  this  has  been 
thoroughly  proved  by  the  experience  of  many  of  our 
states  —  are,  in  the  end,  not  enforced  by  the  so-called 
government,  but  by  the  people  themselves. 

Tobacco 

The  use  of  tobacco  is  generally  regarded  as  a  rather 
expensive,  time-consuming  habit.  Despite  the  some- 
what intemperate  denunciation  of  the  tobacco  habit 
and  the  extravagant  portrayal  of  the  harmful  effects 
of  the  use  of  tobacco,  the  world  at  large  refuses  to 
regard  the  tobacco  problem  as  very  serious  or  im- 
portant. It  is  granted  that  the  first  cigar  usually 
causes  nausea  and  that  some  people  smoke  too  much, 
but,  likewise,  any  unaccustomed  experience,  such  as 
ball  playing,  is  often  accompanied  by  definite  discom- 
fort. Then,  too,  anything  —  even  exercise  and  work 
-  may  be  carried  to  excess.  In  training  for  physical 
contests,  tobacco  is  generally  forbidden,  which  means 
that  the  use  of  tobacco  is  roughly  classified  in  the  same 
category  as  irregular  hours  and  meals  —  that  is  to 
say  as  minor  things  which  tend  to  disturb  the  balance 
of  a  perfectly  adjusted  machine.  The  tobacco  user 
labors  under  no  delusion  that  his  health  is  benefited 
by  the  use  of  tobacco  or  that  he  smokes  from  any  other 
reason  than  his  physical  enjoyment.  Smoking  pro- 
vides him  with  a  trifling  occupation  and  a  pleasurable 
sensation  which  is  extremely  agreeable  and  restful. 

Scientific  investigations  indicate  that  chewing  and 


126  HEALTH  AND  DISEASE 

smoking  of  tobacco  in  any  form  give  the  same  results. 
The  stimulating  effects  of  tobacco  are  so  slight  and 
transitory  as  to  be  negligible.  Tobacco,  as  weed  or 
smoke,  contains  several  poisons,  of  which  the  most 
important  and  the  best  known  is  nicotine.  This  sub- 
stance is  highly  poisonous  to  the  lower  animals,  but, 
so  far,  it  is  impossible  to  correlate  the  findings  in  animals 
with  the  findings  in  man.  The  effects  of  an  excess  of 
tobacco  in  man,  which  means  an  excess  of  nicotine,  are 
fairly  well  known.  There  is  nausea,  and  then  physical, 
mental,  and  nervous  depression.  Some  people  are 
made  temporarily  blind  by  the  excessive  use  of  tobacco. 
Others  develop  the  so-called  "  tobacco  heart ",  which 
is  merely  an  increased  irritability  of  the  nervous 
mechanism  that  regulates  the  heart  action.  This  con- 
dition is  often  alarming,  but  it  ceases  with  the  omission 
of  tobacco  and  there  is  no  evidence  that  there  is  any 
structural  damage  to  the  heart. 

A  fairly  general  effect  of  tobacco,  which  is  somewhat 
similar  in  its  origin  to  the  tobacco  heart,  is  seen  in  the 
acceleration  of  the  pulse  and  the  disturbance  of  the 
blood  pressure  after  the  use  of  tobacco.  These  phe- 
nomena are  due  to  an  increased  irritability  of  the  vaso- 
motor  system,  that  is,  the  nervous  mechanism  which 
regulates  the  size  of  the  blood  vessels  and  the  blood 
flow.  This  condition  is  usually  transitory  and  is  some- 
what similar  to  the  phenomena  observed  in  many 
states  of  nervous  irritability  due  to  excitement  from 
various  causes.  These  phenomena  occur  in  still  other 
conditions  and  their  importance  depends  upon  the 
underlying  causes.  Of  themselves  such  manifesta- 
tions as  an  accelerated  pulse  and  disturbance  of  the 
blood  pressure  are  not  serious.  Like  the  tobacco 
heart,  they  may  give  rise  to  disagreeable  sensations, 
but  there  is  no  evidence,  as  yet,  that  such  manifesta- 
tions, which  subside  rapidly  with  the  disuse  of  tobacco, 


TOBACCO  127 

indicate  organic  heart  disease  or  portend  future  damage 
even  when  made  persistent  through  the  continuance  of 
tobacco. 

The  effect  of  tobacco  smoke  may  be  irritating  to  the 
respiratory  tract.  The  cigarette  smoker's  cough,  for 
example,  is  only  an  evidence  of  such  irritation.  As  an 
irritated  mucous  membrane  favors  infection,  tobacco 
smoking  may  indirectly  cause  disease,  but  there  is  no 
positive  evidence  that  the  use  of  tobacco  causes  cancer, 
as  is  so  often  claimed.  The  excessive  use  of  tobacco 
causes,  as  is  well  known,  an  increased  nervous  rest- 
lessness and  many  susceptible  persons  find  that  an 
increase  of  their  tobacco  allowance  before  bedtime 
will  keep  them  awake  as  effectively  as  an  excess  of 
coffee  will  keep  others  awake. 

In  spite  of  many  attempts  to  throw  upon  tobacco  the 
burden  of  the  causation  of  the  increase  of  our  degenera- 
tive diseases,  the  statistics,  when  scrutinized  carefully, 
have  so  far  been  negative.  Tobacco,  to  be  sure,  is 
largely  used  by  self-indulgent  people.  But  such  people 
sit  long  at  the  table,  consume  considerable  alcohol,  and 
have  many  other  poor  habits  of  hygiene. 

Two  popular  superstitions  in  regard  to  tobacco  re- 
quire a  word.  The  cigarette  is  popularly  regarded  as 
the  most  dangerous  form  of  tobacco.  It  is  perhaps 
true  that  the  cigarette  smoker  gets  more  of  the  con- 
tained poison  than  the  smoker  of  a  pipe  or  cigar.  On 
the  other  hand,  the  poisons  of  tobacco  are  proportional 
to  the  amount  of  tobacco,  and,  during  a  day,  a  cigarette 
smoker  will  get  less  poison,  since  he  will  use  much  less 
tobacco.  This  is  the  common  experience  of  the  be- 
ginner, who  can  often  smoke  a  cigarette  without  dis- 
comfort, but  is  usually  made  ill  by  a  cigar  or  a  pipe. 
Another  superstition  is  that  cigarette  smoking  causes 
all  sorts  of  ills,  perhaps  most  notably  stupidity,  feeble- 
mindedness, and  insanity.  Cigarette  smoking  is  not 


128  HEALTH  AND  DISEASE 

the  cause  of  these  conditions,  but  is  caused  by  them. 
In  other  words,  the  cigarette  habit  is  merely  one  of  the 
many  expressions  of  the  unstable  nervous  system  to 
which  such  people  easily  become  addicted. 

Since  the  use  of  tobacco  is  in  nowise  beneficial  and 
may  disturb  certain  bodily  functions  to  a  greater  or 
less  degree,  the  use  of  tobacco  is,  by  general  consent, 
rightly  denied  to  the  child,  particularly  sensitive  to 
such  disturbances  and  requiring  the  greatest  possible 
efficiency  of  organic  action  for  growth  and  development. 
The  adult,  more  stable  and  less  susceptible,  is  likewise 
not  benefited,  but  he  is  not  greatly  and,  apparently, 
not  permanently  disturbed  by  tobacco. 

In  conclusion,  the  accumulative  evidence  coincides 
with  the  popular  view  and  practice.  The  use  of  to- 
bacco is  in  nowise  beneficial  to  the  health.  It  is  a 
habit,  but  apparently  not  a  vicious  habit.  The  mod- 
erate use  of  tobacco  does  not  shorten  life  nor  in  itself 
cause  serious  disease.  The  excessive  use  of  tobacco, 
like  other  excesses,  is  disturbing  to  certain  bodily 
functions,  mainly  the  stomach,  the  blood  pressure, 
and  the  nervous  system.  However,  the  ill  effects  are 
transitory.  In  general,  the  moderate  use  of  tobacco 
may  be  regarded  as  a  petty  extravagance,  not,  per- 
haps, entirely  harmless,  but  without  any  serious  tram 
of  physical  consequences. 

Patent  Medicines  and  Secret  Nostrums 

Patent  medicines  and  nostrums  may  be  divided  into 
three  classes :  (1)  Those  that  contain  dangerous  and 
habit-forming  drugs  ;  (2)  those  that  contain  legitimate 
remedies;  and  (3)  those  that  contain  no  drug  or 
remedy.  The  first  two  groups  evidently  may  affect 
health.  Legislation  and  publicity  have  largely  elimi- 
nated the  dangers  from  patent  medicines  and  secret 


PATENT  MEDICINES  129 

nostrums,  whereas,  heretofore,  prominent  men  sang 
the  praises  of  patent  medicines  which  were  practically 
whiskey.  Now  merciless  publicity  and  the  bald  state- 
ment of  the  alcoholic  content  on  the  label  have  elimi- 
nated such  articles  as  sources  of  real  danger.  A  man 
now  has  the  requisite  information  so  that  he  can  exer- 
cise his  preference,  if  he  desires  alcohol,  between 
whiskey  and  the  so-called  medicine.  So,  too,  such 
secret  nostrums  as  the  asthma  cure,  which  contained 
a  large  amount  of  cocaine,  have  been  eliminated.  The 
cocaine  did  temporarily  relieve  the  asthma,  but,  in 
the  end,  the  sufferer  had  both  his  asthma  and  a  drug 
habit.  Many  of  the  so-called  pain  killers  and  soothing 
syrups  contained  opium. 

It  should  be  understood,  however,  that  a  patented 
medicine  is  not  necessarily  bad.  Arseno-benzol,  or 
Salvarsan,  Ehrlich's  great  discovery,  so  commonly  known 
as  *'  606,"  is  a  patented  article.  Not  only  the  product 
but  the  process  was  patented.  Many  of  the  coal  tar 
products,  so  widely  used  for  headaches  and  insomnia, 
are  patented  products.  While  there  is  every  justi- 
fication for  the  patenting  of  any  product,  nevertheless 
it  is  to  the  credit  of  medical  science  that,  owing  to  the 
belief  that  human  remedies  and  human  suffering  ought 
not  to  be  capitalized,  few  medical  discoveries  have  been 
patented  or  seem  likely  to  be.  In  all  fairness  it  should 
be  stated  that  the  proceeds  from  the  sale  of  "  606," 
under  the  patent  rights,  are  entirely  devoted  to  the 
development  of  such  scientific  work  as  made  possible 
the  discovery  of  "  606."  Other  patented  products 
which  are  widely  and  legitimately  used  are  certain 
modifications  or  combinations  of  well-known  drugs. 
Adverse  criticism  in  this  case  is  directed  entirely  at 
dishonesty  either  of  an  unusually  high  selling  price  or 
unscrupulous  "  cure-all  "  advertising  methods. 

The  objection  to  the  use  of  any  unknown  so-called 


130  HEALTH  AND  DISEASE 

remedy  must  be  obvious,  even  in  the  absence  of  dan- 
gerous drugs.  Most  secret  nostrums  contain  some 
remedial  agent  which  is  usually  one  that  acts  quickly, 
for  patent  medicines  are  made  to  sell  and  to  make 
money  for  the  owners.  Since  the  benefit  to  the  taker 
is,  of  course,  a  consideration  secondary  to  the  com- 
mercial profit,  the  benefit  depends  solely  on  the  altru- 
ism of  the  seller. 

All  medicine  and  all  drugs,  while  beneficial  in  ap- 
propriate amounts,  are,  nevertheless,  poisons  in  large 
amounts.  Unnecessary  drugging  merely  means  more 
poison,  of  which  the  system  must  rid  itself.  Further- 
more, the  remedial  agents  in  the  average  patented 
medicine  and  nostrum  can  usually  be  purchased  at  a 
small  fraction  of  the  price  of  the  advertised  article. 
Epsom  salts,  so  commonly  used  as  a  purgative,  can  be 
bought  for  a  few  cents  a  pound,  but  in  a  decorated 
bottle  they  usually  cost  many  times  that  amount.  If 
these  arguments  were  not  sufficient,  it  might  be  added 
that  only  in  times  of  serious  trouble  does  Nature  re- 
quire the  aid  of  drugs.  Self -drugging  is  a  pernicious 
habit  and  popular  pills  for  constipation,  for  example, 
have  probably  fastened  constipation  on  more  people 
than  they  have  aided.  Few  cases  of  constipation 
require  adventitious  aids  in  the  form  of  pills,  except 
for  temporary  relief. 

While  people  are  exceedingly  reckless  with  their 
money  and  invest  in  wildcat  schemes,  they  are  much 
more  reckless  with  their  bodies  and  the  drugs  which 
they  administer  to  themselves.  Just  as  people  will 
read  lurid  advertisements  promising  wealth  and  invest 
money  in  gold  mines  in  lands  which  do  not  exist,  so  the 
individuals  read  lurid  advertisements  about  health 
and  buy  medicines  to  cure  ailments  that  they  never  had 
or  which  are  incurable.  Such  advertisements  are  not 
limited  to  medicinal  preparations.  All  sorts  of  medical 


PATENT  MEDICINES  131 

treatments  and  systems  are  advertised  in  the  same  way. 
A  type  of  doctor,  popularly  and  often  correctly  known 
as  a  "  quack ",  uses  screeching  advertisements.  His 
methods  and  his  value  are  those  of  the  objectionable 
patent  medicines  and  secret  nostrums.  Since  it  is 
almost  the  invariable  custom  of  the  medical  profession 
not  to  insert  advertisements  in  the  lay  press,  it  becomes 
a  simple  matter  to  put  a  proper  valuation  on  the 
advertised  promises  and  the  services  of  the  men  who 
advertise. 

A  favorite  ruse  in  the  advertisement  of  a  remedy  or 
of  a  **  quack  "  is  to  enlarge  a  normal  symptom  into 
a  serious  disease  and  guarantee  a  cure.  Most  urines 
will  have  a  brick  dust  sediment  if  left  in  a  cold  vessel. 
This  common  phenomenon  is  frequently  advertised 
as  a  symptom  of  Bright's  disease  and  curable  by  a  few 
bottles  of  some  remedy.  That  the  person  will  be  well 
after  taking  the  medicine  is  a  reasonable  supposition 
if  the  medicine  is  innocuous,  as  it  usually  is. 

A  ruse  which  is  particularly  contemptible,  since  it 
causes  unnecessary  mental  suffering,  is  the  advertise- 
ment of  a  cure-all,  especially  designed  for  sufferers 
from  diseases  so  advanced  as  to  be  incurable.  Of 
course  some  of  the  supposed  sufferers  will  not  be 
diseased  and  so  will  be  easily  "  cured."  But,  in  the 
majority  of  cases,  the  distracted  family  or  friends, 
convinced  by  a  lurid  advertisement  that  a  new  and 
wonderful  cure  has  been  discovered,  fall  victims  to 
their  gullibility  and  their  affection  for  the  sufferer. 
The  enforcement  of  the  law  regarding  the  use  of  the 
mails  to  defraud  and  the  creditable  refusal  of  many 
newspapers  to  accept  such  advertisements,  even  at 
considerable  financial  loss,  are  constantly  tending  to 
protect  the  public  from  these  unscrupulous  schemes. 

It  is  quite  possible  for  a  person  to  go  through  life 
without  the  use  of  drugs.  It  is  possible  for  a  person 


132  HEALTH  AND  DISEASE 

successfully  to  go  through  an  illness  without  drugs. 
Good  habits  of  living  are  far  more  important  than 
drugs  and  it  is  the  part  of  wisdom  to  omit  them  from 
the  daily  life.  Incidentally,  the  household  medicine 
chest,  through  unnecessary  and  unskilled  drugging, 
causes  at  least  as  much  harm  as  good.  Drugs  are 
valuable  and  often  necessary,  but  their  use  should  be 
directed,  not  by  sympathetic  and  unskilled  friends, 
but  by  the  skilled  and  experienced  expert. 

Habit-forming  Drugs 

In  the  United  States,  publicity  and  two  acts  of 
beneficient  legislation  have  largely  eliminated  the 
frightful  dangers  of  the  drug  habit.  By  the  Food 
and  Drug  Act,  commonly  and  incorrectly  known 
as  the  Pure  Food  Law,  articles  of  commerce  con- 
taining the  dangerous  drugs,  including  alcohol,  must 
state  on  their  labels  the  amount  of  such  drugs. 
As  many  of  the  widely  advertised  remedies  contained 
opium,  cocaine,  and  their  derivatives  in  large  amounts, 
the  almost  inevitable  result  of  the  widespread  use  of 
such  products  was  a  large  number  of  innocent  drug 
fiends.  More  recently  the  so-called  Harrison  Law  has 
wisely  restricted  the  sale  of  opium,  cocaine,  and  the 
like.  By  the  provisions  of  this  legislation  it  is  no 
longer  possible  to  buy  these  drugs  over  the  counter, 
and  even  the  doctor's  prescription  has  to  bear  his 
signature  and  his  license  number  under  the  act,  and 
cannot  be  refilled  indefinitely  as  heretofore. 

Probably  we  shall  always  have  some  drug  and 
"  dope  "  fiends,  for  legislation  will  never  prevent  all 
law  breaking.  Moreover,  opium  and  its  derivatives  — 
morphine,  codeine,  heroin,  and  the  like  —  and  cocaine 
and  its  derivatives  are  necessary  medicinal  drugs. 
The  blessings  of  morphine  and  cocaine  are  tremendous, 


HABIT-FORMING  DRUGS  133 

but  their  habitual  use  occasionally  arises  from  their 
use  as  medicine.  It  is  unnecessary  to  dwell  on  the 
effects  of  the  drug  habit.  The  typical  drug  fiend  is, 
and  ought  to  be,  regarded  as  sick,  mentally,  morally, 
and  physically,  and,  too  often,  incurably  sick.  Every 
mental  faculty  and  the  entire  energy  of  the  body  are 
devoted  to  one  purpose  —  the  use  and  procuring  the 
drug  to  which  he  is  enslaved. 

Any  one  who  takes  opium,  cocaine,  or  their  deriva- 
tives, whether  from  the  idle  desire  to  experience  a 
novel  sensation  or  for  the  relief  of  pain,  without  medical 
direction,  is  playing  with  the  deadliest  fire  known  to 
medical  science.  There  are,  of  course,  instances  of 
complete  cures  and  complete  restorations  to  normal 
life,  but  such  cures,  unfortunately,  are  in  the  very 
small  minority.  In  this  country  a  person  must  either 
be  blind  or  a  deliberate  lawbreaker  to  inaugurate  the 
drug  habit. 

While  opium,  cocaine,  and  alcohol  are  the  most 
common,  as  well  as  the  most  important  and  most 
devastating  of  the  habit-forming  drugs,  yet  the  actual 
list  is  long.  There  is  the  ether  habit  and  the  belladonna 
habit,  but  neither  is  common  and  the  habit  does  not 
enslave  the  victim  quite  so  completely  as  opium,  for 
example. 

In  recent  years  the  chemists  have  evolved,  largely 
from  coal  tar  products,  a  number  of  drugs  which  are 
widely  used  for  the  relief  of  headache  or  insomnia. 
Since  these  afflictions  are  recurrent,  many  people  keep 
supplies  of  such  drugs  for  instant  use.  It  is  particu- 
larly true  in  insomnia  that  the  drug  works  well  for  a 
time  and  then  the  dose  has  to  be  increased,  until  sleep 
is  impossible  without  a  tremendous  dosage.  All  these 
drugs  are  depressants  and,  in  excessive  amounts,  may 
cause  death.  The  sleeping  powder  or  tablet  habit  is 
worse  than  insomnia.  Such  drugs  do  not  cure  the 


134  HEALTH  AND  DISEASE 

underlying  causes  of  the  headache  or  the  insomnia; 
they  merely  temporarily  remove  the  objectionable 
symptoms. 

The  indiscriminate  and  unsupervised  use  of  drugs 
tends  to  lead  to  abuse  and  the  incapacitating  drug  habit. 
The  dangers  lurking  in  the  use  of  drugs  are  so  subtle 
and  so  great  that  no  matter  what  the  temptation  may 
be  the  only  wise  course  is  never  to  use  them  except 
under  expert  supervision. 


CHAPTER  VII 

LIGHT  AND  THE  EYES 

WHILE  we  are  accustomed  to  consider  that  the  rays 
of  the  sun  have  performed  their  functions  when  they 
have  given  us  warmth  and  light,  the  sun  rays  have 
other  very  definite  powers.  Sunlight,  for  example,  is 
an  excellent  disinfectant.  Furthermore,  while  the 
subject  is  not  thoroughly  understood,  some  of  the  sun 
rays  have  peculiar  and  mysterious  influences  on  the 
human  body.  An  appreciation  of  the  beneficial  effects 
of  the  sun  rays  has  led  to  their  use  in  the  treatment  of 
disease,  —  heliotherapy.  In  addition,  it  seems  pos- 
sible that  the  beneficial  effect  of  outdoor  living  and 
sleep  may  be  due,  in  part,  to  some  mysterious  activity 
of  the  sun  rays. 

But  the  chief  value  of  the  sun  in  everyday  life  is 
in  the  illuminating  property,  for  most  of  our  activities 
are  directly  dependent  upon  our  ability  to  see.  Loss 
of  sight  is  a  far  greater  industrial  handicap  than  the 
loss  of  limbs  or  of  hearing,  or  of  any  physical  infirmity. 
Under  the  conditions  of  modern  life,  however,  our 
visual  apparatus  frequently  becomes  impaired  through 
the  strains  to  which  it  is  subjected,  and  this,  in  turn, 
leads  to  physical  conditions  which  impair  our  mental 
and  bodily  welfare. 

The  eye  is  a  complex  organ  and  vision  is  a  compli- 
cated physiological  process.  There  is  practically  no 
such  thing  as  a  perfect  eye  or  a  perfect  vision,  but 
most  of  the  imperfections  are  so  slight  as  to  be  negli- 

135 


136  HEALTH  AND  DISEASE 

gible.  The  usual  defects  in  the  eye  are  present  at 
birth,  and  this  is  also  true  of  color  blindness,  a  dis- 
tinctly hereditary  defect  in  vision  —  not  apparently 
in  the  eye  —  which  is  largely  confined  to  males.  These 
congenital  defects  are  usually  defects  of  refraction  of 
light,  but  sometimes  they  are  defects  in  symmetry, 
or  cross  eyes.  Nearsightedness  or  inability  to  see 
well  objects  at  a  distance  is  a  common  condition. 
This  merely  means  that  the  eye  is  improperly  con- 
structed and  that  the  image  of  distant  objects  cannot 
be  focused  on  the  retina.  Nearsightedness,  as  well  as 
the  farsightedness  of  age,  is  easily  corrected  by  glasses, 
and  it  is  imperative  that  such  defects  should  be  cor- 
rected as  soon  as  they  are  detected. 

The  usual  defect  in  the  eye  is  astigmatism,  which 
is  an  inequality  of  curvature  of  one  of  the  refracting 
surfaces  of  the  eye.  Here,  as  always,  Nature  tends 
to  help  defects.  The  squinting  of  a  person  trying  to 
gain  better  vision  merely  means  that  while  the  little 
muscles  within  the  eye  are  trying  to  overcome  some 
handicaps,  unconsciously  the  person  sympathetically 
contracts  certain  external  muscles. 

With  age  definite  changes  occur  in  the  eye.  The 
person  finds,  for  example,  that  he  cannot  focus  at 
nearby  objects,  usually  a  book.  This  condition  is  a 
difficulty  in  mechanism,  since  distant  objects  are  seen 
clearly.  As  Holmes  remarked,  "  My  eyes  are  all 
right,  but  my  arms  are  not  long  enough."  Age  brings 
with  it  real  degeneration  in  the  eye  as  in  other  organs. 
These  changes  can  be  prevented  only  as  age  is  pre- 
vented. 

Eye-strain.  Extraordinary  efforts  on  the  part  of 
Nature  to  overcome  handicaps  may  be  due  not  only 
to  defects  in  the  eye,  but  also  to  overuse  or  to  poor 
illumination.  Whatever  the  cause,  the  result  is  the 
same,  the  so-called  eye-strain.  Overwork  of  the  eyes 


LIGHT  AND  THE  EYES  137 

causes  the  same  train  of  symptoms  of  general  fatigue 
as  any  form  of  overwork.  Eye-strain,  in  particular,  is 
the  cause  of  headache,  dizziness,  and  nausea.  It  of- 
ten occurs  that  a  person  with  supposedly  good  vision 
rather  suddenly  develops  symptoms  of  eye-strain. 
Such  a  sudden  onset  merely  indicates  that,  while 
Nature  had  previously  easily  compensated  for  the 
defect,  a  combination  of  overuse  and  the  defect,  or  a 
combination  of  fatigue  or  illness  and  the  defect,  could 
not  be  counteracted.  Thus,  some  defective  eyes  go 
through  life  without  poor  vision  or  eye-strain,  but  the 
majority  of  people  with  defective  eyes,  who  use  their 
eyes  to  a  considerable  extent,  finally  come  to  the  neces- 
sity of  glasses.  Glasses  merely  correct  the  defect. 
It  is  comparatively  easy  to  select  glasses  for  the  near- 
or  farsighted  person,  but  the  astigmatic  person  requires 
a  delicate  adjustment,  since  an  incorrect  glass  may,  in 
reality,  give  him  more  astigmatism  than  his  original 
defect.  But  the  most  important  factors  in  eye-strain 
are  overuse  and  an  improper  light.  It  should  be  re- 
membered that  the  eyes  are  subject  to  the  same  fatigue 
as  any  other  organ  and  the  early  warning  of  fatigue 
should  be  heeded. 

Illumination.  Strong  light,  either  sun  or  artificial, 
which  shines  either  directly  or  by  reflection,  is  in- 
jurious through  causing  strain.  Snowblindness,  for 
example,  is  caused  by  reflected  sunlight.  From  the 
same  causes,  it  is  important  carefully  to  look  to  our 
light  for  reading  and  to  avoid  as  much  as  possible 
the  smooth  paper  of  certain  books.  With  artificial 
light  the  increased  use  of  the  indirect  and  semi-direct 
system  of  lighting  is  desirable.  Large  halls  bril- 
liantly illuminated  by  scattered  clusters  of  exposed 
bulbs  will  usually  tend  to  increase  strain  of  the  eye, 
since  it  is  nearly  impossible  to  avoid  a  direct  or  re- 
flected intense  light. 


138  HEALTH  AND  DISEASE 

We  have  no  actual  tests  for  insufficient  illumination, 
but  the  consciousness  of  an  enforced  strain  should  be 
adequate  warning.  In  the  matter  of  the  different 
forms  of  illumination,  the  important  consideration 
usually  is  the  securing  of  adequate  light  with  the  avoid- 
ance of  the  direct  intense  light. 

Diseases  of  the  Eye.  The  eye  is  subject  to  a  variety 
of  inflammations,  but  only  three  are  of  general  inter- 
est. Pink  eye  or  conjunctivitis  means  a  superficial  in- 
flammation of  the  eye  caused  by  the  introduction  of 
bacteria.  There  are  epidemics  of  pink  eye,  where  the 
bacteria  are  passed  along  by  some  articles,  usually 
towels,  used  in  common.  Simple  conjunctivitis  is,  as 
a  rule,  not  serious,  but  is  quite  unnecessary,  as  usually 
the  introduction  of  the  bacteria  depends  on  gross 
carelessness. 

Trachoma  is  an  infectious  condition  of  the  lids  and 
the  surface  of  the  eye,  which  seriously  menaces  the 
vision.  It  was  formerly  thought  that  the  disease  was 
largely  confined  to  Europe,  and  stringent  regulations 
were  adopted  to  prevent  the  entrance  of  the  disease 
into  the  United  States.  Recent  investigations  have 
shown,  however,  that  trachoma  is  not  uncommon  in 
this  country.  It  occurs  most  frequently  in  unsanitary 
conditions  and  it  is  spread  by  the  careless  use  of  com- 
mon articles.  The  course  of  the  infection  is  slow  and 
actual  cure  is  not  common. 

One  form  of  conjunctivitis  is  very  serious,  for  the 
inflammation  does  not  remain  superficial,  but  spreads 
to  the  deeper  structures  and  causes  blindness.  This 
form  is  caused  by  the  bacterium  of  gonorrhea,  the 
gonococcus.  This  condition  is  seen  occasionally  in 
careless  adults,  who  thus  pay  a  severe  penalty  for  the 
gonorrhea,  in  the  first  place,  and  for  their  gross  care- 
lessness, in  the  second.  Gonorrheal  conjunctivitis  or 
gonorrheal  ophthalmia,  to  give  the  technical  term, 


LIGHT  AND  THE  EYES  139 

is,  however,  most  common  and  devastating  in  the  new 
born,  and  is  the  cause  of  at  least  ten  per  cent  of  all 
blindness.  About  one  third  of  the  blindness  of  the 
children  in  the  schools  for  the  blind  originated  in  this 
way.  The  baby's  eyes  are  infected  during  the  process 
of  birth,  and,  unless  prompt  and  skilled  treatment  is 
administered  to  the  infected  baby,  the  sight  is  usually 
lost  and  the  child  is  condemned  to  a  life  of  darkness. 
These  cases  are,  unfortunately,  so  common  and  so 
tragic  in  the  outcome,  if  neglected,  that  many  states 
require  immediate  reporting  of  all  suspicious  diseases 
so  that  adequate  treatment  may  be  insured.  All  phy- 
sicians are  urged  to,  and  many  actually  do,  disinfect 
the  eyes  of  all  new  born  babies,  irrespective  of  the 
social  status  of  the  parents. 

Accidents  to  the  eyes  which  entail  partial  or  com- 
plete loss  of  vision  are  common  in  the  modern  industrial 
world.  Employments  which  involve  the  throwing  off 
of  small  particles  of  metal  or  stone  are  especially  a 
menace  to  the  eyes.  Theoretically,  practically  all  in- 
dustrial blindness  is  preventable.  As  a  matter  of  prac- 
tice most  of  the  blindness  is  preventable  through  the 
enforced  use  of  protective  apparatus,  such  as  goggles. 
Certain  poisons,  such  as  lead  and  wood  alcohol,  may 
affect  the  sight,  and  the  excessive  use  of  tobacco  may 
also  cause  temporary  blindness. 

In  general,  the  eyes  are  so  important  that  the  best 
expert  treatment  is  always  justifiable.  Amateur  tink- 
ering with  the  eyes,  even  in  the  removal  of  foreign 
bodies,  may  be  very  costly  to  vision.  Expert  knowl- 
edge is  particularly  important  in  the  fitting  of  glasses 
for  the  astigmatic  eye,  for  it  may  be,  and  usually  is, 
necessary  completely  to  dilate  the  pupil  in  order  satis- 
factorily to  test  the  eye.  When  glasses  are  worn, 
since  they  are  employed  to  correct  refractive  errors, 
it  is  obvious  that  the  glasses  should  be  fixed  accurately 


140  HEALTH  AND  DISEASE 

and  symmetrically.  Accordingly  spectacles  are  more 
desirable  than  eye-glasses.  It  is  remarkable  how  few 
serious  accidents  are  due  to  injury  to  the  eye-ball 
from  broken  glass  of  either  eye-glasses  or  spectacles. 
The  eye  is  well  protected  through  the  reflex  protective 
membrane. 


CHAPTER  VIII 

THE  HYGIENE  OP  THE  TEETH  AND  THE  UPPER 
AIR  PASSAGES 

Dental  Hygiene.  Education  concerning  the  proper 
care  of  the  teeth  has  progressed  to  such  an  extent  in 
the  United  States  that  we,  as  a  people,  have  the  best 
cared  for  teeth  in  the  world.  This  is  a  marked  step 
forward  towards  good  hygiene,  for  many  ills  come  from 
neglect  properly  to  conserve  the  teeth.  Although  it  is 
generally  overlooked,  the  teeth  are  extremely  impor- 
tant in  forming  the  architectural  structure  of  the 
mouth  and  lower  face.  Thus  any  development  de- 
formities in  the  teeth  may  cause  interference  with  the 
functions  of  the  nose  as  well  as  of  the  mouth.  Fur- 
thermore, on  account  of  the  anatomical  proximity, 
diseases  of  the  teeth  are  closely  related  to  diseases  in 
the  nose,  throat,  and  even  the  eyes. 

The  principal  use  of  the  teeth,  of  course,  is  to  masti- 
cate food,  and  this  is  a  vital  process  in  securing  good 
digestion.  Like  the  other  organs  of  the  body,  proper 
exercise  is  necessary  for  the  well  being  of  the  teeth. 
Under  the  artificial  conditions  created  by  civilization 
the  teeth  rarely  get  sufficient  exercise,  which  has  caused 
a  marked  deterioration  in  them  and  necessitated  a 
large  amount  of  care  to  insure  cleanliness  a'nd  prevent 
decay  and  disease.  However,  the  lower  animals,  while 
not  so  dependent  on  frequent  cleaning  of  the  teeth  as 
man,  are  not  exempt  from  dental  disturbances. 

141 


142  HEALTH  AND  DISEASE 

Poor  teeth  may  be  inherited,  or  they  may  be  the 
result  of  malnutrition  on  account  of  illness  during  their 
development,  or  they  may  be  the  end  result  of  faulty 
care.  The  last  factor  is  by  far  the  most  important, 
and  this  is  preventable.  While  theoretically  a  proper 
diet  might  be  supposed  to  keep  the  teeth  healthy  and 
clean,  experience  shows  that  healthy  and  clean  teeth 
are,  in  general,  exactly  relative  to  the  use  of  cleaning 
methods,  the  toothbrush,  the  toothpick,  and  dental 
floss. 

The  decay  of  teeth  is  roughly  proportional  to  the 
amount  of  accumulated  food.  The  food  not  only 
brings  bacteria,  but  furnishes  a  good  culture  medium 
for  the  bacteria  which  are  normally  present  in  the 
mouth.  The  chemical  products  of  the  bacterial  action 
and  the  bacteria  themselves  attack  the  teeth  and  de- 
cay results.  Decayed  teeth  mean  interference  with 
mastication  and  tend  to  inaugurate  digestive  disturb- 
ances. Furthermore,  decayed  teeth  eventually  mean 
infection.  Of  late  we  have  been  discovering  the  im- 
portant role  of  infection  in  and  around  the  teeth  in 
systemic  disease.  Certain  mysterious  fevers  and  forms 
of  rheumatism  can  be  traced  directly  to  infected  teeth. 
Good  teeth  are  a  definite  cosmetic  asset,  while  poor 
teeth  cause  pain,  suffering,  and  economic  loss.  Poor 
teeth  are  a  source  of  digestive  disturbance  and  infected 
teeth  are  an  important  cause  of  systemic  disease. 

The  prevention  of  these  conditions  lies  in  simple 
cleansing  of  the  teeth  and  gums.  Preferably  the  teeth 
should  be  cleaned  after  each  meal.  In  any  event 
accumulated  food  should  not  be  allowed  to  remain 
overnight.  While  the  teeth  of  certain  fortunate  indi- 
viduals are  easily  cleaned,  most  people  require  the  use 
of  a  brush  and  a  fine,  simple  powder  in  order  to  insure 
cleanliness.  Others  rapidly  accumulate  on  their  teeth 
a  substance  which  infects  the  gums  and  causes  Rigg's 


UPPER  AIR  PASSAGES  143 

disease  (pyorrhea  alveolaris)  or  receding  gums.  In 
such  cases  the  periodic  aid  of  a  dentist  is  required  to 
keep  the  teeth  clean. 

The  vigorous  exercise  of  the  teeth,  scrupulous  clean- 
liness, and  frequent  visits  to  the  dentist  to  detect  and 
eradicate  incipient  decay  are  simple,  but  effective, 
means  of  insuring  sound  teeth. 

The  Upper  Air  Passages  (the  Nose,  Throat,  and 
Ears).  The  chief  function  of  the  nose  and  throat  is  to 
make  the  air  which  goes  into  the  lungs  warm  and  moist. 
In  complete  mouth  breathing  this  important  function  is 
inadequately  performed.  In  addition  the  mouth  and 
throat,  of  course,  serve  as  the  passageway  by  which 
food  gets  into  the  stomach,  and  the  whole  anatomy  of 
the  nose  and  throat  is  designed  for  the  increasing  of 
resonance.  The  anatomical  connection  of  all  these 
structures  is  an  important  consideration,  since  it 
affords  the  opportunity  for  an  easy  extension  of  infec- 
tion and  disease  from  any  one  to  all. 

The  upper  air  passages  are  the  main  avenue  by  which 
disease  germs  enter  the  body.  It  is  obvious  that  when 
we  breathe  air  which  contains  bacteria,  these  micro- 
organisms will  be  drawn  into  the  respiratory  tract  in 
the  process  of  breathing.  The  peculiar  anatomical 
structure  of  the  nose  and  throat,  with  their  large  con- 
voluted surface  area,  especially  adapted  to  heat  and 
moisten  the  inspired  air,  also  enables  these  surfaces 
to  act  as  a  filter  for  particles  of  dust  and  moisture, 
many  of  which  contain  bacteria.  There  is  a  large 
group  of  diseases  —  colds,  tonsillitis,  whooping  cough, 
diphtheria,  bronchitis,  tuberculosis,  and  pneumonia 
—  whose  effects  are  largely  confined  to  the  respiratory 
tract.  The  disease  germs  are  given  off  in  droplets  in 
breathing,  as  well  as  in  coughing  and  sneezing.  There 
is  another  large  group  of  diseases,  as  measles  and  small- 
pox, in  which  the  disease  may  be  regarded,  perhaps,  as 


144  HEALTH  AND  DISEASE 

more  general,  but  the  avenue  of  infection  is  through  the 
upper  respiratory  tract  through  the  infective  droplets 
given  off  by  persons  having  the  disease.  There  is  no 
sharp  differentiation  between  the  diseases  of  these 
two  groups.  A  purely  local  infection  may,  at  any  time, 
become  general.  In  pneumonia,  for  example,  the 
disease  germs  are  often  present  in  the  blood  stream. 
Moreover,  in  all  these  conditions  the  infective  bacteria 
are  present  in  the  discharge  from  the  nose  and  throat. 

The  Common  Cold.  Statistics  collected  in  Boston 
show  that  more  time  and  money  are  lost  through  the 
common  cold  than  through  any  other  cause.  Conse- 
quently, contrary  to  the  general  belief,  the  common 
cold  is  of  real  industrial  as  well  as  of  hygienic  impor- 
tance. Colds,  as  most  of  us  have  learned  through  our 
own  experience,  cause  inconvenience  and  suffering, 
and  may  produce  permanent  damage  in  addition  to 
economic  loss.  Among  the  possible  complications  and 
sequelae  of  the  common  cold  may  be  listed  rheumatic 
fever,  pneumonia,  nephritis,  and  a  depressed  vitality 
which  allows  other  infections  to  get  a  hold  on  the  body 
or  aids  the  progress  of  organic  disease. 

Bacteria  of  disease  are  almost  inevitably  present  in 
the  air  we  breathe  in  our  daily  intercourse  with  people. 
Adequate  ventilation  and  reasonable  individual  care 
will  limit,  but  not  eliminate,  the  breathing  in  of  bac- 
teria. Consequently  we  are  continually  forced  to 
rely  on  other  defenses  against  air-borne  infections. 
In  order  to  avoid  these  infections  transmitted  through 
the  upper  air  passages  the  individual  must  start  with 
a  normal  nose  and  throat,  for  abnormal  conditions  of 
these  structures  always  favor  infection.  It  is  a  com- 
mon experience  that  the  correction  of  abnormality  of 
the  nose  and  throat,  such  as  a  deviated  septum  and 
enlarged  tonsils,  often  rids  the  individual  of  the  ten- 
dency to  recurrent  colds. 


UPPER  AIR  PASSAGES  145 

The  second  defense  against  these  infections  is 
keeping  in  good  bodily  condition.  Constipation,  for  in- 
stance, through  lowered  bodily  resistance,  may  in- 
directly cause  a  cold,  and  so  a  dose  of  salts,  calomel, 
or  castor  oil  may  assist  in  the  rapid  disappearance  of 
a  cold.  Vitiated  air,  dust,  drafts,  sudden  changes  of 
temperature,  exposure  to  wet  and  cold,  overwork, 
loss  of  sleep,  improper  food,  all  lead  to  a  reduction  in 
vitality  and  so  allow  infection  to  develop. 

Irritations  of  the  nose  and  throat  are  also  contribu- 
tory factors  in  causing  colds.  Foremost  in  these  irri- 
tations is  that  from  dry,  hot  air.  Smoke,  dust,  and 
fog  are  also  important  irritants. 

Three  things,  then,  the  abnormal  anatomy  of  the 
nose  and  throat,  the  physical  condition  of  the  body, 
and  irritations,  are  the  contributing  factors  to  causing 
colds,  and  their  connection  is  important  in  the  pre- 
vention of  colds  and  other  air-borne  infections.  But 
the  actual  causes  of  these  diseases  are  bacteria.  The 
general  superstition  that  colds  are  due  to  drafts,  chill- 
ing of  the  body,  and  the  like  has  only  the  basis  in  fact 
that  they  produce  a  condition  favorable  for  the  devel- 
opment of  the  bacteria  which  are  always  necessary  to 
produce  the  cold  or  other  infection.  Colds  are  con- 
tracted from  other  people  who  have  colds.  The  men 
who  went  on  expeditions  with  Peary  to  the  polar  regions 
did  not  suffer  from  colds  in  spite  of  the  low  temper- 
ature, because  there  were  no  bacteria  there.  An  appre- 
ciation of  the  droplet  method  of  infection  will  go  a 
long  ways  toward  decreasing  the  number  of  colds.  It 
is  only  in  this  way  that  the  cold-causing  bacteria  are 
transmitted  from  one  person  to  another  and  that  colds 
are  actually  contracted. 

Besides  the  ordinary  cold  —  the  term  may  be 
stretched  to  include  laryngitis  and  tonsillitis  or  sore 
throat,  —  there  are  other  definite  infections  of  the 


146  HEALTH  AND  DISEASE 

nose  and  throat.  The  so-called  children's  diseases  — 
diphtheria,  scarlet  fever,  measles,  and  the  like  —  have 
their  origin  in  the  nose  and  throat.  So  it  happens 
that  oftentimes  when  a  person  is  supposed  to  be  com- 
ing down  with  a  so-called  cold,  he  is,  in  reality,  coming 
down  with  one  of  these  diseases.  For  this  reason,  as 
well  as  to  stop  cold  infections,  logically,  we  should 
quarantine  for  ordinary  colds  as  much  as  we  quaran- 
tine for  measles  or  any  of  the  children's  diseases.  The 
only  difference  between  measles  and  colds,  for  example, 
is  that  the  complications  of  measles  justify  a  more 
strict  quarantine.  It  is  only  fair  and  reasonable, 
then,  that  the  individual  who  has  a  cold  should  take 
it  upon  himself  to  see  to  it  that  he  does  not  spread  the 
infection  and  thus  endanger  the  health  of  others. 

Adenoids  and  Diseased  Tonsils.  At  birth  there 
are  certain  structures  in  the  throat,  which  are  known 
as  adenoids.  As  the  child  grows  older,  these  tend  to 
disappear  and  in  adult  life  they  are  of  little  conse- 
quence. On  the  other  hand,  adenoids  hi  a  child  may 
be  of  serious  import.  They  may  prevent  breathing 
through  the  nose  and,  by  causing  mouth  breathing, 
cause  the  well-known  adenoid  facies  with  the  large 
receding  chin  and  change  the  entire  appearance  of  the 
face.  Abnormal  breathing  through  the  mouth  seems 
seriously  to  affect  not  alone  the  physical  development 
and  energy,  but  also  the  mental  development  and 
energy.  Many  backward  and  stupid  children  become 
normal  and  alert  pupils  after  the  removal  of  their  ade- 
noids. These  growths  should  be  treated  as  any  other 
obstruction  of  the  nose  and  throat  and  they  usually 
require  removal  by  a  surgical  operation. 

The  tonsils  are  particularly  important  in  the  ques- 
tion of  disease  and  its  prevention,  because  it  is  through 
the  tonsils  that  germs  of  great  importance  in  the  pro- 
duction of  disease  get  into  the  body.  Rheumatic 


UPPER  AIR  PASSAGES  147 

fever,  for  instance,  almost  always  starts  with  an  infec- 
tion of  the  tonsils.  Through  the  tonsils  come  the 
infections  which  cause  the  damaged  kidneys  and  hearts 
in  young  people.  Thus,  at  the  first  sign  that  the  ton- 
sils are  failing,  usually  on  account  of  disease,  properly 
to  act  as  filters  and  that  bacteria  are  permitted  to  pass 
through,  the  tonsils  should  be  removed.  If  the  ton- 
sils are  not  removed,  in  a  case  of  heart  disease  for  in- 
stance, the  disease  will  frequently  tend  to  increase, 
through  a  repetition  of  the  infection  from  the  diseased 
and  poorly  functioning  tonsils. 

The  Eustachian  Tubes.  A  little  behind  the  ton- 
sils, leading  from  the  throat,  are  the  Eustachian  tubes 
which  serve  as  the  connection  between  the  throat  and 
the  ears.  On  account  of  this  connection,  when  we 
have  a  cold,  our  ears  feel  as  though  they  were  stopped 
up.  So,  too,  if  there  is  an  irritation  in  the  nose  and 
throat,  germs  may  travel  through  the  Eustachian 
tubes  and  cause  trouble  in  the  ears,  such  as  earaches 
or  even  abscesses.  Whenever  the  Eustachian  tubes 
become  blocked,  it  makes  the  anatomy  of  the  ear  ab- 
normal and  the  probability  of  infection  becomes  in- 
creasingly likely.  As  a  matter  of  fact  deafness,  which 
rarely  starts  out  in  a  very  acute  fashion,  may  result 
from  such  an  infection.  Deafness  is  the  end  result  of 
chronic  troubles  with  the  nose  and  throat  since  the 
chances  always  favor  the  eventual  extension  to  the  ears. 

Hygiene  of  the  Ear.  The  hygiene  of  the  external 
ear  may  be  summed  up  by  saying  that  absolutely 
nothing  should  ever  be  inserted  in  it.  Wax,  caused 
by  the  sebaceous  glands,  and,  apparently,  a  natural 
thing,  is  always  present  in  the  external  ear.  This 
wax  may  interfere  with  hearing,  but  it  should  only  be 
removed  by  an  expert.  In  general,  the  presence  of  a 
normal  nose  and  throat  free  from  infections  is  the  best 
insurance  of  sound  ears  and  good  hearing. 


148  HEALTH  AND  DISEASE 

The  Sinuses.  In  the  face  and  head  are  several 
bony  structures  which  contain  air  arid  are  connected 
with  the  nose  and  throat.  The  chief  function  of  these 
structures  is  to  increase  resonance.  Above  the  eyes 
are  the  frontal  sinuses ;  the  antrum  of  Highmore  is  on 
either  side  of  the  nose  and  helps  to  make  up  the  cheek 
bone,  and  the  ethnoid  and  sphenoid  cells  are  also  in 
close  proximity  to  the  nose.  The  mastoid  cells  are 
connected  with  the  internal  ear  and  make  up  a  bony 
prominence  behind  the  external  ear.  All  these  struc- 
tures may  be  diseased  by  the  simple  direct  extension 
of  infection.  Mastoid  infection  may  be  extremely 
serious  on  account  of  the  close  proximity  to  the  brain. 
Infection  of  the  frontal  sinuses  is  not  uncommon  and 
is  the  cause  of  troublesome  headaches. 

Catarrh.  No  word  is  more  commonly  used  in  con- 
nection with  diseases  of  the  nose  and  throat  than  the 
word  catarrh.  As  a  matter  of  fact  catarrh  is  a  symp- 
tom and  not  a  disease  in  itself.  It  simply  means  that 
the  mucous  membrane  of  the  nose  and  throat  is  not 
normal.  Climates  with  sudden  changes  often  cause 
catarrh.  Occupations  may  also  cause  it.  A  man 
working  in  a  quarry,  for  example,  breathes  in  dust  and 
the  chances  are  that  he  will  get  catarrh  as  an  expres- 
sion of  irritation  of  the  mucous  membrane.  Smoking 
also  increases  the  irritation  of  the  nose  and  throat. 
As  a  result  the  person  who  smokes  too  much  must  be 
prepared  to  put  up  with  this  irritation. 

On  account  of  the  inevitable  close  proximity  of  peo- 
ple necessitated  by  modern  life,  it  is  impossible  to  in- 
sure complete  freedom  from  air-borne  diseases.  The 
individual  can  do  much  by  the  exercise  of  personal  pre- 
cautions, particularly  when  he  is  infected.  Further- 
more, sound  general  hygiene  of  the  body  and  the  cor- 
rection of  abnormalities  of  the  upper  air  passages  and 
the  avoidance  of  irritation  are  of  great  assistance  in 


UPPER  AIR  PASSAGES  149 

increased  resistance  and  in  eliminating  footholds  for 
lurking  bacteria.  The  promiscuous  use  of  gargles  and 
nasal  douches  is  not  to  be  recommended,  since  the 
antiseptic  power  is  necessarily  slight.  Most  substances 
sufficiently  powerful  to  kill  bacteria  also  irritate  and 
usually  damage  the  tissues.  Washing  the  throat  with 
bland  substances  like  water  (gargling)  is  usually  harm- 
less and  often  beneficial  in  the  event  of  infection. 
Uncommonly  gargling,  but  frequently  washing  the 
nose  (douching),  serves  to  spread  the  infection.  Since 
colds,  as  are  many  of  the  infections  of  the  upper  air 
passages,  are  definitely  limited  diseases,  any  measures 
except  those  directed  towards  general  hygiene  should 
be  undertaken  only  on  expert  advice. 


CHAPTER  IX 

THE  HYGIENE  OF  THE  MIND  AND  NERVOUS  SYSTEM 

The  Nervous  System  and  Disease.  In  considering 
the  nervous  system  it  is  important  to  realize  that  the 
same  food  which  nourishes  the  muscles  also  nourishes 
the  brain  and  nervous  system.  Both  the  muscles  and 
the  nervous  system  are  built  up  in  the  same  way.  The 
nervous  and  mental  systems  are  poisoned  in  the  same 
way  as  any  other  system  in  the  body  is  poisoned.  Like 
the  other  organs,  the  nerves  and  brain  share  in  general 
poisonings  and,  likewise,  are  peculiarly  susceptible  to 
certain  poisons.  We  see  them,  for  example,  becoming 
abnormal  and  poisoned  in  many  of  the  contagious 
diseases.  We  have  the  temporary  delirium  in  the 
course  of  typhoid  fever,  for  instance,  and  also  in  the 
course  of  many  other  fevers.  We  are  all  familiar  with 
the  fact  that  a  person  is  weak,  both  mentally  and  phys- 
ically, after  an  illness,  and  especially  after  an  illness 
associated  with  delirium.  After  some  diseases,  actual 
insanity  may  ensue.  Excessive  fatigue  may  also  cause 
delirium. 

Certain  poisons,  as  alcohol,  lead,  morphine,  co- 
caine, and  the  like  have  a  particularly  selective  damag- 
ing effect  on  the  mind  and  nervous  system.  The 
delirium  of  alcoholic  intoxication  is  entirely  mental, 
and  the  same  is  true  of  cocaine  and  morphine  poison- 
ing. Twelve  per  cent  of  all  the  first  admissions  to 
insane  hospitals  are  due  to  poisoning  by  alcohol. 
Their  minds  were  disturbed  through  the  effects  of 

150 


HYGIENE  OF  THE  MIND  151 

alcohol  and  these  effects  may  be  more  or  less  perma- 
nent. All  drug  habitues  have  wrought  serious 
damage  to  the  mind  and  nervous  system. 

Even  more  important  in  its  effects  upon  the  mental 
and  nervous  systems  is  the  disease  syphilis.  More 
than  thirteen  per  cent  of  the  first  admissions  to  in- 
stitutions for  the  insane  are  due  to  syphilis.  The 
chances  of  recovery  in  the  case  of  syphilitics  are  not 
so  good  as  in  the  case  of  alcohol.  With  an  alcoholic 
it  is  possible  to  purge  the  system  of  poison  and  build 
up  the  body  again.  On  the  other  hand,  in  syphilis, 
while  a  certain  number  are  curable,  by  the  time  the 
disease  strikes  the  nervous  system  a  large  number  of 
cases  are  incurable  because  changes  have  actually 
taken  place  in  the  brain  and  nervous  system. 

Injuries.  Traumatic  injuries  to  the  head  may  cause 
serious  damage  to  the  mental  faculties,  although  the 
seriousness  and  nature  of  the  damage  depend  upon  the 
localization  of  the  injury.  It  is  often  remarkable  that 
the  injury  and  subsequent  loss  of  considerable  brain 
tissue  in  certain  regions  is  accompanied  by  no  serious 
loss  of  mental  faculty  or  nervous  function.  A  slight 
injury  in  another  situation  may  cause  death  or  the 
most  serious  damage. 

Inheritance  and  Mental  Disease.  Heredity  is  easily 
the  most  important  single  factor  in  the  problem  of 
mental  and  nervous  disturbances.  Certain  forms  of 
insanity  are  largely  determined  by  heredity.  Feeble- 
mindedness is  almost  exclusively  hereditary.  Then, 
too,  the  widely  varying  grades  of  mental  and  nervous 
irritability  and  instability  are  usually  inherited.  In 
such  instances  the  individual  environment,  which 
includes  nutrition,  training,  education,  as  well  as  the 
immediate  surrounding  influences  of  poverty,  work, 
worry,  and  fatigue  determine  the  ultimate  condition 
of  the  mind  and  nervous  system. 


152  HEALTH  AND  DISEASE 

"  Stress  of  Life."  An  important  factor  in  mental 
hygiene  is  the  so-called  stress  of  life.  There  are  many 
people  who  maintain  their  mental  and  nervous  equilib- 
rium under  the  sedative  influences  of  a  perfectly  normal 
and  quiet  life,  but  who,  under  different  conditions, 
will  go  insane.  Such  people  are  always  potentially 
insane,  but  the  disease  will  not  manifest  itself  until 
conditions  of  life  are  changed.  This  condition  has 
been  particularly  apparent  in  the  case  of  immigrants 
who  have  completely  changed  their  habits  and  methods 
of  living.  Any  taint  of  insanity  or  mental  or  nervous 
instability  due  to  heredity  is  apt  to  come  out  under 
the  stress  of  life.  But  a  sound  and  average  person, 
with  a  sound  heredity,  will  undergo  the  most  tremen- 
dous changes  in  environment  without  disturbing  his 
mental  or  nervous  poise. 

The  economic  state  of  an  individual  plays  a  consider- 
able part  in  the  problem  of  mental  and  nervous  hygiene. 
Only  the  rugged  can  withstand  with  equanimity  the 
attendant  ills  and  struggles  of  poverty.  On  the  con- 
trary, the  wealthy  man  with  a  bad  heredity  can  pur- 
chase unhygienic  excess  and  increase  his  liability  to 
his  inherited  tendency.  The  two  economic  extremes 
often  produce  the  same  results. 

Perhaps  the  most  important  asset  in  mental  and 
nervous  hygiene  is  the  cultivation  of  sound  habits. 
Good  habits  will  compensate  greatly  not  only  for  bad 
inherited  tendencies  and  poor  environment  but  also  for 
the  almost  inevitable  stress  and  strain  of  modern  life, 
for  in  this  way  we  can  control  the  evil  effects  of  fatigue. 
In  the  same  way  we  can  combat  all  the  evils  of  our 
economic  conditions,  whether  that  condition  be  one  of 
prosperity  or  of  poverty.  All  the  discussions  of  mind 
and  nerve  cures  preach  the  same  doctrine,  and  many 
have  recently  emphasized  the  futility  and  absurdity  of 
unnecessary  worry.  Fatigue  and  worry  are  integral 


HYGIENE  OF  THE  MIND  153 

parts  of  the  same  vicious  circle,  which  must  be  in- 
terrupted if  possible.  The  work  cure,  the  recreation 
cure,  the  rest  cure,  the  self-forgetting  cure,  all  turn  on 
an  appreciation  and  utilization  of  the  fundamental 
principles  of  hygiene  and  the  related  factors  of  rest, 
work,  and  fatigue. 


CHAPTER  X 

THE  COMMUNICABLE  DISEASES 

Early  History  of  Communicable  Diseases.  Our 
environment  surrounds  us  with  many  dangers  which 
tend  to  shorten  life,  interfere  with  our  health,  and  de- 
stroy our  happiness.  By  far  the  most  important  of 
these  dangers  are  the  communicable  diseases.  The 
danger  from  communicable  diseases  is  ever  present; 
it  may  lurk  in  the  air  we  breathe,  in  the  food  and  drink 
we  take,  on  whatever  or  whomever  we  touch,  or  from 
the  bites  of  insects  and  animals.  By  a  communicable 
disease  we  mean  a  disease  which  may  be  communicated, 
directly  or  indirectly,  from  person  to  person.  Through 
loose  usage  the  words  communciable,  infectious,  con- 
tagious, and  "  catching  "  as  applied  to  diseases  are 
essentially  synonymous.  But  by  the  use  of  the  prefer- 
able term,  communicable,  we  do  not  commit  ourselves 
to  the  method  of  transfer  of  the  disease  or  to  the 
nature  of  the  disease. 

That  some  diseases  at  least  were  communicated  or 
were  **  catching  "  has  been  believed  since  the  earliest 
times.  The  common  people  early  convinced  themselves 
of  this  fact,  while  the  so-called  scientists  were  wrangling 
over  the  spontaneous  generation  of  disease  or  arguing 
whether  or  not  disease  represented  a  visitation  of  Provi- 
dence.- The  Old  Testament  tells  us  of  the  fixed  belief 
that  the  leper  was  dangerous  to  the  touch.  Hippoc- 
rates insisted  that  many  diseases  were  communicated 
from  person  to  person,  and  mentioned  smallpox  in 

154 


THE   COMMUNICABLE  DISEASES       155 

the  list.  DeFoe,  in  his  account  of  the  plague  in  London, 
tells  us  of  the  well-defined  and  well-grounded  belief 
that  the  disease  could  be  communicated.  Indeed 
tradition  and  history  are  full  of  accounts  of  plagues 
and  epidemics  from  which  the  survivors,  certain  of 
the  communicable  nature  of  the  pestilence,  sought 
safety  in  flight. 

While  the  belief  that  some  diseases  at  least  were 
communicated  by  touch  or  other  method  was  fairly 
firmly  established,  the  exact  causative  agents  remained 
unknown  until  recent  years.  The  most  fanciful  theories 
and  the  wildest  superstitions  sprang  up  concerning  the 
immediate  causes  of  communicable  diseases.  Jenner's 
discovery  of  the  protective  value  of  cowpox  against 
smallpox,  at  the  end  of  the  eighteenth  century,  was 
founded  on  empirical  grounds  and  did  not  directly  aid 
in  the  solution  of  the  mystery.  Bacteria  were  observed 
as  early  as  1673.  In  1762  we  find  the  recorded  doc- 
trine which  ascribed  to  every  disease  its  particular 
micro-organism.  But  such  ideas  were  isolated  and 
escaped  general  attention.  In  1843,  Oliver  Wendell 
Holmes,  by  brilliant  reasoning,  suggested  that  puer- 
peral fever  (childbed  fever)  was  a  communicable 
disease  and  was  probably  transferred  by  doctors  and 
nurses.  The  conservative  medical  profession  fairly 
skrieked  its  indignation  and  bitterly  attacked  Holmes 
and  his  theory.  The  result  was  a  masterpiece,  in  both 
the  literary  and  scientific  sense,  from  the  pen  of 'Holmes. 
In  the  meantime  modern  medical  science  was  being  born. 

The  Work  of  Pasteur.  Enormous  progress  had  been 
made  in  physics,  chemistry,  physiology,  and  the  allied 
sciences.  In  1858  the  publication  of  Virchow's  cellular 
pathology  placed  the  study  of  disease  on  a  firm  founda- 
tion. Accurate  instruments  of  investigation,  chief 
among  them  the  microscope,  were  being  developed. 
Then  came  Louis  Pasteur  (1822-1895),  the  father  of 


156  HEALTH  AND  DISEASE 

bacteriology.  In  view  of  his  achievements  in  the  field 
of  medicine  it  is  remarkable  to  relate  that  Pasteur  was 
educated  as  a  chemist.  In  the  investigation  of  all  his 
problems  he  applied  scientific  and  laboratory  methods. 
In  1860  occurred  a  famous  controversy  concerning 
spontaneous  generation.  The  supporters  of  this  theory 
maintained  that  the  cloudiness  of  beer,  wine,  and  of 
clear  broths  was  due  to  the  development  of  certain 
substances  de  novo.  Pasteur  and  his  adherents  claimed 
that  such  fluids  were  contaminated  from  the  vessel 
or  from  the  air,  and  that  this  contamination  was  caused 
by  the  growth  of  minute  microscopic  particles,  the 
"  infinitesimally  small."  Pasteur  also  showed  that  the 
heating  of  such  fluids  (subsequently  known  as  pasteur- 
ization) stopped  the  development  of  the  contamination. 
He  took  the  precious  flasks  which  he  used  in  his  experi- 
ments to  the  Alps  and  opened  them  there  to  demon- 
strate that  the  pure  air  of  the  mountains,  free  from 
human  contamination,  contained  fewer  of  these  minute 
particles. 

The  first  great  work  of  Pasteur  concerned  itself  with 
industrial  diseases.  He  showed  that  the  various  fer- 
mentations were  due  to  the  presence  and  growth  of 
minute  organisms  and  that  the  spoiling  of  beer  and 
wine,  for  instance,  could  be  prevented  by  heating  them 
at  a  low  temperature  (pasteurization).  The  heating 
prevented  the  growth  of  the  minute  particles  but  did 
not  affect  the  taste.  He  then  began  to  recognize  and  to 
grow  in  artificial  media  these  minute  particles,  micro- 
organisms, microbes,  or  germs.  The  next  step  in 
Pasteur's  work  in  bacteriology  was  to  attribute  the 
cause  of  many  diseases  to  these  germs,  with  the  result 
that  from  1870-1890  people  said  as  now,  *'  This 
microbe  business  is  getting  to  be  a  joke.  Do  they 
want  us  to  believe  that  everything  is  caused  by  a 
microbe  ?  "  But  in  1877-1879  Pasteur  was  able,  by 


THE  COMMUNICABLE  DISEASES       157 

a  dramatic  series  of  incidents,  to  demonstrate  that  the 
dreaded  charbon  of  cattle  (anthrax),  which  was  dev- 
astating France  and  had  cost  millions  of  francs, 
was  caused  by  one  of  these  microbes  and,  furthermore, 
he  was  able  successfully  to  vaccinate  against  it.  By 
the  knowledge  that  Pasteur  gained  from  his  study  of 
the  infecting  organism,  he  was  able  to  suggest  pre- 
ventive measures  which  eradicated  the  disease.  From 
that  time  on  the  causative  agent  of  one  communicable 
disease  after  another  was  discovered.  Pasteur  lived 
to  see  the  discovery  by  one  of  his  pupils  of  diphtheria 
antitoxin  in  1894,  after  the  diphtheria  bacillus  had 
been  discovered  by  others. 

In  1881  Koch,  in  Germany,  published  his  work 
announcing  not  only  the  discovery  of  the  tubercle 
bacillus,  the  causative  agent  of  tuberculosis,  but  also 
all  the  important  facts  concerning  that  micro-organism. 
In  England,  Lister  utilized  these  discoveries,  especially 
those  of  Pasteur,  and  thus  modern  surgery  began. 
Pasteur  first  saw  clearly  the  r61e  of  micro-organisms 
in  the  cause  of  disease.  He  studied  their  life  and  habits. 
He  promulgated  the  important  doctrine  of  vaccination 
against  disease.  He  developed  the  cure  of  disease  by 
antitoxin.  In  the  brief  span  of  one  life  the  concep- 
tion of  communicable  diseases  changed  from  that  of 
the  visitation  of  the  mysterious  agencies  of  the  Evil 
One  to  the  effects  of  infection  by  a  definite  micro- 
organism that  could  be  combated. 

We  have  learned  that  many  diseases,  childbed  fever 
for  example,  not  commonly  thought  to  be  commu- 
nicable, are  positively  caused  by  micro-organisms. 
While,  since  earliest  times,  a  few  supposed  fanatics  had 
claimed  that  consumption  was  communicable,  the  gen- 
eral belief  had  been  that  it  was  either  hereditary  or  a 
"  visitation  ",  until  the  truly  epoch-making  discovery 
of  Koch  cleared  up  for  all  time  the  mystery  of  its  causa- 


158  HEALTH  AND  DISEASE 

tion.  By  bacteriological  research  it  was  learned  that 
apparently  different  disease  appearances  were  only 
different  manifestations  of  the  same  micro-organism. 
Thus  bacteriology  violently  disarranged  all  the  pre- 
vious concepts  of  disease.  It  was  the  appreciation  of 
these  discoveries  in  bacteriology  that  made  modern 
surgery  possible,  that  made  child  birth  relatively  safe, 
and  has  given  us  a  considerable  part  of  the  knowledge 
necessary  to  fight  communicable  disease. 

As  yet  not  all  the  infinitesimally  small  agencies 
which  cause  disease  have  been  discovered.  We  do  not 
know  the  precise  micro-organisms  which  cause  yellow 
fever,  measles,  and  some  other  diseases.  We  do  not 
know  how  leprosy  and  anterior  poliomyelitis  (infantile 
paralysis)  are  spread.  Although  each  year  adds  to 
our  knowledge,  increased  knowledge  is  still  necessary, 
as  diseases  are  preventable  only  in  proportion  to  what 
we  know  of  them. 

Exact  and  complete  knowledge  is  essential  to  the 
nghting  of  disease,  and  particularly  so  in  the  case  of 
the  communicable  diseases.  In  order  to  undertake  the 
prevention  of  a  communicable  disease  with  some  assur- 
ance of  success,  it  is  necessary  to  know  the  cause,  the 
life  history  of  the  micro-organism,  how  it  is  transferred, 
and  the  cure  of  the  disease.  Yet  the  application  of 
reasonably  adequate  knowledge  may  be  extremely 
difficult  for  a  variety  of  reasons.  In  syphilis,  for 
example,  we  have  a  complete  knowledge  of  the  cause 
of  the  disease ;  we  known  exactly  how  it  is  carried ;  we 
can  recognize  the  germ,  and  we  have  a  satisfactory 
treatment  in  that  it  will  practically  cure  all  cases,  but 
we  cannot  eradicate  the  disease.  The  personal  element 
is  so  great  a  factor  in  syphilis  that  we  are  absolutely 
unable  to  prevent  the  social  conditions  that  favor  the 
transmission  of  the  disease.  Tuberculosis  is  in  theory 
preventable,  but,  practically,  the  nature  of  the  disease 


THE  COMMUNICABLE  DISEASES       159 

is  such  that  it  is  difficult  of  prevention.  On  the  other 
hand  in  some  diseases  while  we  know  much  about  them, 
even  how  to  prevent  them,  we  do  not  know  the  cause. 
Yellow  fever,  for  example,  is  always  transmitted  by 
the  bite  of  a  particular  mosquito  and  we  know  how  to 
prevent  the  disease  without  knowing  the  causative 
micro-organism.  Again  we  do  not  know  the  organism 
which  causes  smallpox,  yet  we  can  protect  entirely  against 
this  disease  by  vaccination.  While  the  prevention  of 
disease  depends  upon  our  knowledge  of  it,  it  is  signifi- 
cant that  a  little  knowledge  will  enable  us  to  prevent 
one  disease,  while  an  extensive  knowledge  may  not 
always  suffice  for  the  prevention  of  another  disease 
with  peculiar  characteristics. 

The  great,  outstanding  fact  concerning  all  the  com- 
municable diseases  is  that  the  causative  agents  are 
minute  forms  of  life,  both  animal  and  vegetable.  Their 
size  varies  from  ultra-microscopic,  that  is,  so  small  that 
these  forms  of  life  cannot  be  seen  by  the  magnification 
of  our  microscopes,  to  certain  animal  forms,  like  some 
of  the  worms,  which  are  readily  visible  to  the  naked 
eye.  Even  in  the  case  of  the  large  animal  forms  the 
infection  is  usually  transferred  by  means  of  eggs  which 
are  microscopic.  Thus,  in  general,  we  refer  in  a 
somewhat  loose  way  to  micro-organisms  or  microbes, 
meaning  merely  the  minute  forms  of  life,  either  vege- 
table or  animal,  of  which  a  certain  proportion  are  asso- 
ciated with  disease. 

Classification  of  Micro-organisms.  There  are,  of 
course,  many  possible  divisions  and  subdivisions  of 
these  micro-organisms  according  to  their  many  char- 
acteristics. A  reasonably  satisfactory  classification  is 
to  divide  them  into  three  groups :  (1)  the  bacteria, 
which,  in  a  loose  terminology,  includes  all  forms  of 
vegetable  micro-organisms;  (2)  the  protozoa  or  the 
simple  animal  micro-organisms ;  (3)  and  the  metazoa 


160  HEALTH  AND  DISEASE 

or  higher  and  more  complicated  forms  of  animal  life, 
as  the  worms.  Such  a  classification  depends  upon 
the  structure  of  the  micro-organism  and  not  upon  its 
relation  to  disease.  Only  a  comparatively  small  pro- 
portion of  the  minute  forms  of  animal  and  vegetable 
life  are  hostile  to  man  and  cause  disease.  The  presence 
or  absence  of  micro-organisms  is  not  the  essential  fea- 
ture. Whether  the  micro-organism  is  pathogenic  to 
man  is  the  vitally  important  line  of  differentiation. 

The  Bacteria.  Bacteria  are  minute  vegetable  parti- 
cles which  can  only  be  seen  through  a  microscope. 
Some  fifteen  hundred  kinds  of  bacteria  have  been  de- 
scribed and  others  are  being  discovered  constantly. 
Bacteria  are  present  everywhere,  —  in  the  air,  in 
water,  in  the  soil,  and  throughout  Nature. 

But  not  all  bacteria  are  harmful.  For  example, 
bacteria  perform  such  useful  purposes  as  giving  flavor 
to  cheese  and  buttermilk.  Fermentation  is  usually  a 
bacterial  action.  Plant  and  animal  life  would  dis- 
appear without  bacteria,  for  it  is  largely  bacterial 
action  that  prepares  food  for  vegetable  life  and  growth 
as  is  well  seen  in  the  nitrogen  and  carbon  cycle. 

We  can,  therefore,  divide  the  bacteria  into  two 
classes  —  the  pathogenic,  which  cause  disease,  and  the 
non-pathogenic,  which  are  harmless  or  semi-beneficial. 
This,  however,  is  not  always  a  definite  distinction,  for  a 
bacterium  non-pathogenic  in  one  situation  may  become 
pathogenic  in  another.  Our  intestines,  for  example, 
contain  many  forms  of  bacteria  which  are  non-patho- 
genic, but  which,  if  placed  under  the  skin,  would  be 
pathogenic. 

Bacteria  may  be  subdivided  into  several  groups, 
depending  on  their  morphology.  The  small  round 
forms  are  called  cocci  or  micrococci.  In  addition  to 
having  differences  in  activity  and  in  causing  different 
diseases,  these  micrococci  have  definite  characteristics 


THE  COMMUNICABLE  DISEASES       161 

of  morphology  and  growth.  Thus  we  speak  of 
the  micrococcus  of  pneumonia,  the  pneumococcus, 
the  micrococcus  of  gonorrhea,  the  gonococcus,  and  the 
micrococcus  which  is  the  common  pus  maker,  the 
staphylococcus,  or  to  give  the  full  name  the  staphylo- 
coccus  pyogenes  aureus. 

The  bacilli  are  the  various  rod-like  forms  of  bacteria. 
The  bacillus  group  is,  perhaps,  the  most  important 
from  the  viewpoint  of  disease,  as  it  includes  the  typhoid 
bacillus,  the  tubercle  bacillus  (the  micro-organism  of 
consumption),  the  diphtheria  bacillus,  and  the  like. 

A  spirillus  is  merely  a  twisted  rod.  An  example  in 
disease  is  the  spirillum  of  Asiatic  cholera. 

A  spirochaeta  is  a  rod  which  appears  in  twists  like  a 
corkscrew.  Some  observers  prefer  to  classify  the  spiro- 
chsetae  as  an  animal  form  of  life.  Many  spirochsetse, 
however,  grow  like  vegetable  forms.  The  most  notable 
example  of  the  spirochaetae  is  the  spirochaeta  pallida 
of  syphilis  or,  more  accurately,  treponema. 

Some  of  the  higher  and  more  complicated  forms 
of  vegetable  life,  the  fungi  or  molds,  occasionally  cause 
disease.  We  may  loosely  include  here  such  causative 
agents  as  the  tinea  of  "  ring- worm  "  and  the  acti- 
nomyces  which  cause  actinomycosis. 

With  the  perfection  of  our  technical  methods,  it  is 
probable  that  other  groups  will  have  to  be  added, 
since  there  is  every  reason  to  believe  that  measles, 
yellow  fever,  and  scarlet  fever  are  caused  by  some  form 
of  bacterial  life,  although  we  are  not  yet  able  to  dis- 
cover the  causative  agent.  Apparently  some  of  these 
causative  agents  are  so  minute  as  to  baffle  discovery 
by  our  present  microscopes.  These  ultra-microscopic 
forms  of  micro-organism,  presumably  bacteria,  may 
represent  additional  types  of  bacteria. 

The  Protozoa  and  Metazoa.  The  second  large 
group  of  infecting  agents  is  the  group  of  small  animals 


162  HEALTH  AND  DISEASE 

—  the  protozoa.  These  are  simple,  one-celled  animals, 
of  which  the  simplest  form  is  the  amoeba.  A  few  of 
the  amoebae  are  pathogenic.  Malaria  is  caused  by  a 
protozoon.  The  trypanosome  that  causes  sleeping 
sickness  is  a  form  of  protozoa. 

The  third  group  of  infecting  agents  is  that  of  the 
metazoa  and  includes  the  various  worms,  —  the  tape- 
worms, the  pin-worm,  hook-worm,  trichinae,  and  the 
like. 

Characteristics  of  Bacteria.  Since  they  cause  most  of 
the  communicable  diseases,  the  members  of  the  bacterial 
group  are  the  most  important.  Bacteria  have  no  one 
essential  characteristic.  Some  are  extremely  motile, 
as  the  typhoid  bacillus,  while  some  reproduce  rapidly 
and  others  slowly.  A  typhoid  bacillus  will  grow  large 
numbers  overnight,  while  it  takes  a  week  to  get  a 
considerable  growth  of  the  tubercle  bacillus.  Then 
certain  forms,  known  as  the  anaerobes,  will  not  live 
in  the  presence  of  oxygen,  while  others,  the  aerobes, 
will  live  only  in  the  presence  of  oxygen.  Others  grow 
easily  with  or  without  oxygen. 

Certain  of  the  bacteria,  such  as  the  anthrax  bacillus, 
produce  spores,  —  which  is  a  form  of  hibernation.  The 
spore  is  a  small  capsulated  object  in  which  the  organism 
seems  to  hibernate.  Spores  are  difficult  to  kill  and  it 
may  require  boiling  for  a  long  time  to  accomplish  this. 

In  general,  bacteria  reproduce  rapidly  and  the  average 
bacterium  will  reproduce  in  about  half  an  hour.  This 
is  accomplished  by  division  or  fission,  provided  favor- 
able conditions  are  present. 

Just  as  some  bacteria  prefer  oxygen  and  some  do  not, 
each  form  of  bacteria  has  certain  peculiarities  of  growth 
both  within  and  without  the  body.  Some  bacteria 
grow  easily  in  any  organ  or  anywhere  that  they  can  find 
nourishment.  Others  will  only  grow  in  certain  organs 
within  the  body  and  under  special  conditions  outside. 


THE  COMMUNICABLE  DISEASES       163 

All  bacteria  require  food,  although  the  requirements 
vary  widely.  In  general  the  pathogenic  bacteria 
thrive  best  at  a  temperature  approximately  that  of  the 
body  (37.5°  C.  or  98.4°  F.).  Also  bacteria  like  moisture 
and  darkness.  By  reversing  these  conditions  we  can 
hinder  or  prevent  bacterial  growth.  As  we  cultivate 
bacteria  in  a  dark  thermostat  on  a  moist  media,  so  we 
prevent  their  growth  outside  by  exposure  to  light,  by 
cold  or  heat,  by  dryness,  and  by  the  absence  of  suit- 
able food.  Outside  of  the  body,  in  addition,  we  make 
use  of  the  various  more  positive  methods  which  actually 
destroy  the  bacteria  rather  than  inhibit  their  growth. 

The  Destruction  of  Bacteria  Outside  the  Body.  At 
first  thought  it  might  seem  possible  to  kill  all  the  patho- 
genic bacteria  wherever  they  exist.  But  it  must  be 
remembered  that  the  non-pathogenic  bacteria  are 
necessary  for  life  and  that  we  cannot  always  distin- 
guish definitely  between  pathogenic  and  non-patho- 
genic bacteria.  There  are  a  number  of  means  of  kill- 
ing bacteria.  As  surgery  began,  for  example,  there 
was  a  wide  use  of  disinfectants.  Lister  performed  his 
operations  in  the  midst  of  a  carbolic  acid  spray  which 
was  supposed  to  kill  all  the  bacteria  in  the  operating 
field  and  in  the  surrounding  air.  But  a  continued 
use  of  these  disinfectants  has  proven  unsatisfactory. 
Bacteria  must  be  regarded  as  a  form  of  life,  and  the 
use  of  disinfectants  which  kill  bacterial  life  will  also 
destroy  other  kinds  of  life.  The  use  of  disinfectants 
will,  for  instance,  tend  to  kill  the  cells  of  the  hands, 
while  it  is  almost  impossible  to  use  disinfectants  in 
the  throat  without  killing  the  cells  of  some  of  the  deli- 
cate membranes.  But  in  their  place  disinfectants  play 
an  important  and  necessary  r61e. 

Three  main  methods  are  in  use  against  bacteria. 
First,  we  use  the  physical  properties  which  Nature 
provides,  as  light  and  heat.  Most  bacteria  prefer 


164  HEALTH  AND  DISEASE 

darkness  and  some  bacteria  cannot  live  at  all  in  the 
presence  of  sunlight.  A  combination  of  sunlight  and 
sunheat  is  an  admirable,  though  slow,  method  of  de- 
stroying bacteria.  The  violet  ray  kills  bacteria 
promptly.  Sufficient  heat  will  kill  all  forms  of  life. 
Pasteur  early  found  that  heating  at  60°  C.  (144°  F.)  for 
half  an  hour  killed  most  of  the  ordinary  forms  of 
bacteria.  Heat  may  be  used  directly  or  as  dry  heat  or 
moist  heat,  often  under  pressure,  or  in  boiling.  But, 
obviously,  there  are  many  things  which  we  desire  to 
free  from  bacteria,  such  as  books,  which  cannot  be 
subjected  to  heat  without  destroying  the  article  itself. 
Boiling,  as  in  the  case  of  surgical  instruments,  is,  per- 
haps, the  best  method  of  killing  bacteria.  Boiling 
for  a  limited  period  will  kill  all  known  bacteria.  Moist 
heat  under  pressure  is  very  effective  and  is  the  method 
of  choice  for  sterilizing  clothes,  surgical  dressings,  and 
the  like. 

The  second  group  of  agents  used  to  kill  bacteria  is 
comprised  of  the  chemicals,  which  are  usually  employed 
in  the  form  of  a  liquid  or  of  a  gas.  Few  chemical  dis- 
infectants can  be  used  about  the  human  body  in  suffi- 
cient concentration  to  be  really  effective.  Carbolic 
acid  is  the  oldest  disinfectant.  The  salts  of  mercury 
(bichloride  of  mercury  or  corrosive  sublimate),  although 
valuable  disinfectants,  have  the  disadvantage  that  they 
corrode  metals.  They  also  form  inert  and  insoluble 
compounds  with  albuminous  matter,  such  as  blood  and 
pus.  Finally,  they  are  extremely  poisonous,  as  the  toll 
of  deaths  from  the  accidental  or  intentional  taking  of 
corrosive  sublimate  shows.  The  most  modern  chemical 
disinfectant  is  formalin,  a  solution  of  formaldehyde 
gas.  This  is  an  admirable  disinfectant  and  can  be  used 
where  a  large  number  of  others  are  impossible  or  use- 
less. Lime,  either  in  the  form  of  chloride  of  lime  or 
quick  lime,  has  been  known  as  a  disinfectant  for  many 


THE   COMMUNICABLE  DISEASES       165 

years.  It  is  widely  used  as  a  disinfectant  of  feces, 
sewage,  and  garbage  and  is  cheap.  It  should  always 
be  freshly  prepared.  Alcohol  is  one  of  the  best  dis- 
infecting agents  which  we  have.  It  can  be  used  on 
the  skin,  for  example,  without  injury  to  the  tissues. 

All  the  acids  are  powerful  disinfectants,  but  they  are 
not  employed  extensively  on  account  of  their  general 
destructive  properties.  There  are,  of  course,  many 
other  liquid  disinfectants  and  various  modifications  of 
those  mentioned,  especially  of  carbolic  acid  (phenol). 

Two  disinfectants,  which  are  not  active  on  bacteria 
in  general  but  which  are  very  effective  for  special  use, 
are  sulphate  of  copper  and  chlorine.  Sulphate  of 
copper,  in  a  weak  solution,  is  used  in  water  and  swim- 
ming pools  to  destroy  the  algae  and  many  bacteria. 
Unfortunately  in  such  solution  sulphate  of  copper  has 
little  or  no  effect  on  the  typhoid  bacillus.  Chlorine 
as  such  or  as  bleaching  powder,  when  added  to  water, 
will  kill  bacteria  in  such  dilution  that  the  taste  of  the 
water  is  hardly  affected. 

The  value  of  all  the  liquid  disinfectants  depends  on 
the  complete  immersion  of  the  article  to  be  disinfected, 
for  in  no  other  way  is  penetration  obtained.  It  is 
evident  that  air  cannot  be  disinfected  in  this  way,  and 
that,  as  a  rule,  neither  can  a  room. 

Fumigation.  From  time  immemorial  substances  in 
the  form  of  gas  have  been  used  as  disinfectants.  This 
procedure  is  termed  fumigation.  In  point  of  fact  the 
value  of  most  of  these  substances,  usually  created  by 
burning,  was  to  act  as  a  deodorant  or  to  overwhelm 
the  original  disagreeable  odor  by  another  more  pun- 
gent. The  actual  disinfecting  power  of  most  of  these 
gases  is  slight.  The  use  of  sulphur  as  a  true  disinfectant 
has  been  discontinued.  While  sulphur  is  extremely 
effective  in  killing  mosquitoes  and  other  insects,  it 
does  not  kill  bacteria  except  in  the  presence  of  moisture. 


166  HEALTH  AND  DISEASE 

Formaldehyde  gas,  however,  under  suitable  condi- 
tions is  extremely  efficient.  It  is,  at  present,  the  usual 
method  applied  to  the  disinfection  of  rooms  and  houses. 
There  are  a  number  of  devices  for  the  production  or 
liberation  of  formaldehyde  gas.  This  gas  must  be 
used  at  a  temperature  of  65°  F.  or  higher  and  with  an 
initial  humidity  of  sixty-five  per  cent.  A  skilled  person 
must  be  employed  to  disinfect  with  this  gas  for  it  must 
be  confined  within  the  room  to  be  disinfected  and  the 
creation  of  a  disagreeable  odor  is  by  no  means  synony- 
mous with  disinfection. 

Indirect  Methods  of  Controlling  Bacteria.  The  third 
method  of  destruction  of  organisms  is  not  a  direct 
method,  but  works  indirectly.  By  this  method  bacteria 
are  denied  entrance  to  their  normal  habitats  where  they 
multiply  rapidly,  and  conditions  are  made  so  unsatis- 
factory and  unfavorable  for  the  bacteria  that  they  die 
without  any  reproduction  of  their  kind.  Withholding 
all  food  is  an  excellent  method  of  destroying  bacteria. 
This  method  of  the  destruction  of  organisms  requires 
the  intelligent  application  of  our  knowledge  of  the 
habits  of  bacteria.  By  such  means,  for  example,  are 
we  able  to  preserve  food.  Likewise  we  establish  the 
principles  of  asepsis  in  surgery  as  opposed  to  antisepsis. 
By  antisepsis  we  mean  the  killing  off  of  bacteria;  by 
asepsis,  keeping  the  field  free  from  bacteria.  In  other 
words,  it  is  really  more  effective  to  prevent  the  entrance 
of  bacteria  than  to  kill  them  off  after  they  have  entered. 
The  preparation  of  the  hands  for  a  surgical  operation  is 
a  case  in  point.  It  is  more  effective  to  rid  the  hands  of 
all  dirt  and  bacteria  and  to  encase  them  in  clean  rubber 
gloves  than  to  apply  antiseptics  which  will  kill  the 
bacteria  and,  perhaps,  damage  the  hands.  The  action 
of  soap  and  water  is  largely  mechanical.  The  bacteria 
are  washed  off  and  are  prevented  from  reaching  places 
where  they  multiply  rapidly. 


THE  COMMUNICABLE  DISEASES       167 

This  same  principle  is  utilized  in  the  care  of  both 
water  and  milk  and  in  the  treatment  of  sewage.  The 
important  consideration  in  the  treatment  of  milk  is  the 
prevention  of  contamination  of  the  milk,  rather  than 
the  killing  of  the  bacteria  after  their  entrance.  In  the 
treatment  of  a  water  supply,  water  that  is  kept  for  a 
certain  period  of  time  and  freed  from  substances  which 
will  feed  bacteria  becomes  practically  bacteria  free. 
Sewage,  which  is  put  into  dry  earth  where  it  cannot 
contaminate  drinking  water  and  thus  re-enter  the 
human  body  where  the  bacteria  again  multiply  rapidly, 
will  help  to  fertilize  the  land  and  the  pathogenic  bacteria 
will  die  out. 

The  Practical  Use  of  Disinfectants.  All  of  the  three 
methods  and  modifications  of  these  methods  are  utilized 
in  everyday  life.  We  can,  perhaps,  best  illustrate  by 
the  problem  of  preventing  the  spread  of  infection  from 
a  patient  with  such  a  disease  as  typhoid  fever. 

The  discharges  of  such  a  sick  person,  particularly 
the  feces,  contain  dangerous  typhoid  micro-organisms. 
The  sputum  and  nasal  discharges  may  well  be  received 
on  gauze  or  paper  or  in  sputum  cups  and  burnt.  The 
most  efficient  chemicals  for  the  disinfection  of  sputum 
are  carbolic  acid  5%,  formalin  10%,  and  chlorinated 
lime  3%.  The  urine  and  feces  should  not  be  poured 
into  a  sewer  that  has  an  unknown  outlet.  The  urine,  un- 
contaminated  with  feces,  which  do  not  allow  the  proper 
admixture  of  chemical  substances,  can  be  disinfected 
by  the  same  chemicals  as  the  sputum.  The  non-fluid 
feces  can  be  burnt,  preferably  in  an  incinerator.  All 
chemicals  used  to  disinfect  feces  should  be  allowed  to 
stand  in  contact  for  at  least  an  hour  and  sufficient 
quantities  should  be  used.  Lime  is  particularly  valu- 
able, but  it  should  be  remembered  that  air-slaked  lime 
is  inert.  Lime  and  water  in  proportion  of  one  to  four, 
freshly  mixed  and  in  sufficient  amount  to  cover  and 


168  HEALTH  AND  DISEASE 

thoroughly  impregnate  the  material,  are  effective,  if 
allowed  to  stand  for  two  hours.  Likewise  an  equal 
amount  of  5%  carbolic  acid  or  10%  formalin  will  dis- 
infect in  about  an  hour. 

Everything  which  touches  the  patient  may  be  in- 
fected. Therefore  all  bed  and  body  clothes,  towels, 
napkins,  and  the  like  should  be  boiled.  They  may  be 
immersed  in  carbolic  acid  5%,  formalin  10%,  or  bi- 
chloride of  mercury  (corrosive  sublimate)  one  to  1,000. 
Such  clothing  soiled  by  albuminous  secretions,  like 
blood  and  pus,  will  be  stained  permanently  if  boiled 
directly,  and  hence  they  may  be  first  washed  in  cold 
water,  which  is  then  boiled  or  disinfected.  Dishes 
should  be  treated  with  boiling  water. 

While  disinfection  of  the  room  is  not  necessary  in  the 
case  of  typhoid  as  it  is  in  the  case  of  the  air-borne  in- 
fections, as  smallpox,  it  is  often  desirable  to  treat  the 
room.  All  articles  in  the  room  which  can  be  treated  by 
heat,  either  moist  heat  under  pressure  or  dry  heat,  or 
boiling  are  so  treated.  Any  useless  articles  can  be 
burned.  The  room  is  then  treated  to  gaseous  disinfec- 
tion by  the  selected  method.  Formaldehyde  disinfec- 
tion is  the  most  generally  useful.  The  experienced 
handler  of  this  disinfectant  will  see  to  it  that  a  sufficient 
amount  of  gas  is  liberated,  that  the  outlets  of  the  room 
are  effectively  closed,  and  that  the  materials  in  the  room 
are  so  managed  that  the  gas  can  penetrate  and  disinfect. 

Carpets,  rugs,  and  the  like  are  often  not  thoroughly 
disinfected  by  formaldehyde  gas  and  it  is  desirable 
that  they  should  be  removed  subsequently  and  sub- 
jected to  moist  heat.  In  some  instances  saturation 
with  formalin  solution  will  suffice.  Again,  exposure  to 
strong  sunlight  will  act  effectively.  Books  are  not 
common  carriers  of  disease  despite  the  impression  to 
the  contrary.  Thoroughly  contaminated  books  should 
be  burnt.  On  the  other  hand,  books  merely  present 


THE  COMMUNICABLE  DISEASES       169 

in  the  room  are  rendered  harmless  by  cleansing.  In 
addition,  there  are  several  special  disinfecting  devices 
for  contaminated  books. 

In  addition  to  these  precautions,  after  the  disinfec- 
tion a  thorough  mechanical  cleaning  and  a  prolonged 
exposure  to  sun  and  air  are  eminently  desirable.  In  the 
case  of  measles  and  whooping  cough,  in  which  we 
know  that  the  infecting  agents  are  only  transmitted  by 
immediate  contact,  these  latter  precautions  amply  suf- 
fice. In  point  of  fact  we  are  learning  constantly  that 
most  bacteria,  away  from  a  favorable  resting  place, 
such  as  soil,  water,  milk,  feces,  and  the  human  body, 
do  not  exist  for  any  length  of  time  and  that,  with  the 
removal  of  such  substances  by  simple  cleanliness,  the 
danger  of  communication  is,  in  most  instances,  ex- 
tremely slight  after  the  lapse  of  such  a  period  of  time 
as  a  few  days.  There  is  an  increasing  tendency  to 
discontinue  terminal  infection  by  chemical  means  and 
to  concentrate  on  thorough  mechanical  cleansing. 

The  human  element  is  the  chief  communicating  one 
and  is  difficult  of  disinfection.  By  the  intelligent 
appreciation  of  what  carries  infection  and  what  does 
not  and  by  scrupulous  cleanliness,  there  is  little  danger. 
In  these  days  doctors  rarely  carry  infection,  although 
passing  from  patient  to  patient.  In  the  first  place  the 
doctor  touches  as  little  contaminated  material  as 
possible.  In  many  instances  he  wears  a  gown  and 
gloves  in  the  sick  room.  After  his  visit  he  washes  his 
hands,  thoroughly.  While  nurses  and  doctors  contract 
typhoid  through  the  handling  of  patients,  it  is  on  ac- 
count of  carelessness,  but  not  always  on  the  part  of  the 
victim.  In  the  case  of  air-borne  infections,  the  danger 
is  greater  and  the  protection  is  less.  Still,  by  avoiding 
close  proximity  to  the  patient  and,  particularly,  his 
breathing,  with  the  cooperation  of  the  patient  the 
danger  of  infection  is  greatly  lessened. 


170  HEALTH  AND  DISEASE 

The  Destruction  of  Bacteria  within  the  Body.  It 
might  be  thought  that  when  bacteria  get  into  the  body 
they  would  tend  to  grow  until  the  infected  person 
died.  The  doctrine  of  the  self-limitation  of  disease 
has  been  accepted  only  comparatively  recently.  All 
diseases  are  not  self-limited.  But  we  are  familiar 
with  what  is  known  as  the  typical  course  of  a  disease, 
which  is  uninfluenced  by  treatment.  Measles  runs  a 
definite  course  of  a  few  days  and  typhoid  of  a  few  weeks, 
yet  the  exact  mechanism  that  brings  about  this  limita- 
tion of  disease  and  a  spontaneous  cure  is  not  well 
understood. 

The  outcome  of  disease  may  be  considered  to  depend 
upon  three  factors :  the  number  of  bacteria  in  the  ini- 
tial dose ;  the  virulence  of  the  bacteria,  and  the  resist- 
ance of  the  body. 

To  a  considerable  extent,  at  least  in  some  diseases, 
and  well  illustrated  by  certain  experimental  conditions 
in  animals,  the  intensity  of  disease  (and  its  outcome) 
depends  on  the  number  of  bacteria  entering  the  body. 
But  this  is  not  always  true.  We  can  speak  more  defi- 
nitely on  the  question  of  virulence.  The  mortality 
statistics  show  that  some  epidemics  are  notoriously 
severe,  while  others  are  mild.  This  indicates  that  the 
infecting  bacteria  are  not  always  of  uniform  virulence. 
At  times  this  virulence  is  increased,  and  at  times 
decreased.  In  the  laboratory  the  virulence  of  a  micro- 
organism can  occasionally  be  altered. 

Resistance  of  the  Individual  to  Infection.  The  most 
important  fact  in  the  intensity  and  the  outcome  of  a 
disease  is  usually  the  resistance  of  the  individual,  — 
the  natural  immunity  or  the  natural  susceptibility  and 
the  antagonistic  reaction  of  the  individual's  tissues 
against  the  disease.  This  resistance  varies  enormously. 
Certain  persons  are  notoriously  susceptible  to  all 
forms  of  communicable  diseases;  others  seem  to  be 


THE  COMMUNICABLE  DISEASES       171 

immune.  So,  also,  do  people  vary  after  the  disease 
has  been  contracted,  —  some  offer  little  resistance, 
while  others  offer  the  most  stubborn  resistance  to  the 
onslaught  of  the  particular  disease.  We  see  in  the 
different  animals  perhaps  the  widest  variations  in 
resistance.  Typhoid  fever  is  peculiarly  a  disease  of 
man  and  cannot  be  given  to  animals.  Certain  kinds  of 
mice  are  susceptible  to  the  pneumococcus,  while 
others  are  practically  immune.  There  are  some  diseases 
which  the  body  apparently  does  not  resist  at  all,  as  the 
pneumonic  plague,  which  seems  to  be  always  fatal. 

We  know  little  positively  concerning  the  mechanism 
of  resistance  and  the  defense  of  the  body.  If  a  person 
has  smallpox  or  yellow  fever  and  has  recovered,  he  is 
generally  immune  from  the  disease  and  will  never  con- 
tract it  again.  This  is  known  as  acquired  immunity 
as  contrasted  with  natural  immunity.  There  is  a 
definite  tendency  for  one  attack  of  many  diseases  to 
protect  against  other  attacks.  The  application  of  this 
is  the  underlying  factor  in  vaccination,  for  vaccination, 
whether  against  smallpox,  typhoid,  or  anthrax,  merely 
consists  in  giving  the  individual,  by  means  of  an 
attenuated  or  modified  virus,  a  mild  form  of  the  disease 
and  thus  affording  him,  in  part  at  least,  the  protection 
that  an  attack  of  the  disease  would  give. 

In  certain  diseases  one  attack  does  not  protect  against 
another.  In  pneumonia,  one  attack  seems  to  render 
the  individual  more  liable  to  a  second  attack.  In 
point  of  fact  one  attack  does  afford  protection,  but  this 
lasts  for  but  a  short  time.  When  the  protection  is 
lost,  the  mechanical  damage  to  the  lungs  favors  a 
subsequent  attack.  The  same  holds  true  of  colds, 
rheumatic  fever,  diphtheria,  and  gonorrhea.  Since  the 
attack  of  the  disease  does  not  afford  protection,  it  is 
evident  that  vaccination,  from  its  very  nature,  can  ac- 
complish nothing  against  these  particular  diseases. 


172  HEALTH  AND  DISEASE 

Some  individuals  are  naturally  protected  against 
certain  diseases,  as  diphtheria,  for  instance.  There  is 
something  in  their  blood  which  opposes  the  growth  of 
the  bacillus  at  its  entrance.  This  seems  to  be  more  or 
less  a  slowly  acquired  racial  and  hereditary  charac- 
teristic. With  us  measles  is  a  mild  disease,  but  the 
people  of  the  South  Sea  Islands  were  killed  off  right 
and  left  by  an  epidemic  of  the  disease.  The  conclusion 
is,  that  because  we  have  had  measles  for  so  many  years, 
a  certain  degree  of  protection  is  hereditary.  So  the 
early  ravages  of  syphilis  in  Europe  were  more  severe 
than  those  of  to-day. 

From  time  to  time  we  have  believed  that  we  knew 
how  this  protection  worked.  But  the  theory  of 
phagocytosis,  for  example,  that  the  bacteria  which 
come  into  the  body  are  fought  and  eaten  by  the  white 
cells  of  the  blood,  by  no  means  entirely  explains  resist- 
ance. We  now  presuppose  the  existence  in  the  blood 
of  certain  theoretical  substances,  not  demonstrable 
chemically,  but  often  demonstrable  biologically  (that 
is  by  their  activity  in  various  ways  against  the  particular 
micro-organism)  which  we  designate  as  anti-bodies. 
We  presuppose  and  can  demonstrate  biologically  a 
different  set  of  anti-bodies  for  each  micro-organism. 
Ehrlich  has  brilliantly  outlined  this  doctrine  in  his 
side-chain  theory  of  immunity. 

After  bacteria  gain  an  entrance  into  the  body,  they 
can  act  in  one  of  two  ways.  They  can  act  through 
their  own  presence  or  through  a  poison  which  all 
bacteria  elaborate  and  which  is  known  as  a  toxin.  This 
toxin  may  be  widely  diffused,  or  it  may  remain  inside 
the  bacteria  themselves.  There  may  be  one  or  more 
toxins.  Both  bacteria  and  toxins  irritate  the  tissues 
of  the  body. 

Bacterial  Toxins  or  Poisons.  The  baneful  effects 
of  bacteria  are  due,  in  a  general  way,  to  the  toxins 


THE  COMMUNICABLE  DISEASES       173 

elaborated  by  them.  These  toxins  are  not  demon- 
strable chemically,  but  they  seem  to  be  substances 
similar  to  the  snake  venoms.  Again  in  a  general  way, 
the  toxins  of  bacteria  are  highly  poisonous  and  re- 
produce the  general  picture  of  the  disease.  A  char- 
acteristic of  toxins  is  that  if  they  are  injected  into 
animals,  antitoxins  are  produced.  There  is  considerable 
evidence  that  some  of  the  activity  of  the  toxins  is 
attributable  to  the  medium  in  which  the  bacteria 
grow.  Theoretically  at  least,  it  is  evident  that  in 
resisting  disease  two  or  more  substances  antagonistic 
to  bacteria  must  be  developed.  One  substance  — 
antitoxin  —  will  neutralize  the  toxin  which  may  be 
causing  the  damage  at  a  considerable  distance  from  the 
growing  bacteria.  We  have  a  beautiful  illustration  of 
this  in  the  use  of  the  diphtheria  antitoxin.  Antitoxin 
occurs  most  abundantly  in  the  blood  stream,  but  it  is 
also  present  in  the  fixed  tissues.  The  chemical  nature 
is  unknown  beyond  the  fact  that  it  is  a  protein  sub- 
stance, a  globulin  or  attached  to  the  globulins.  An- 
other substance  will  attack  the  bacteria  themselves, 
a  true  bactericidal  agent.  It  seems  probable  that 
the  development  of  these  substances,  while  not  pre- 
cisely parallel,  tends  to  be  more  or  less  so.  In  the 
spontaneous  cure  of  disease  these  substances  antagonis- 
tic to  bacteria  and  their  products  are  developed  suffi- 
ciently to  eradicate  the  disease.  In  some  diseases  the 
body  retains  a  sufficient  supply  of  these  antagonistic 
substances  to  afford  immunity  for  life.  In  other 
diseases  this  immunity  is  short  lived. 

Antitoxins.  Since  the  discovery  of  bacteria  and  the 
beginning  of  knowledge  concerning  their  methods  of 
action,  medical  science  has  been  endeavoring  to  secure, 
by  artificial  means,  antagonistic  substances  which  will 
act  in  the  same  curative  fashion  as  the  natural  products. 
Vaccination  is  merely  the  creation  of  the  natural  antag- 


174  HEALTH  AND  DISEASE 

onistic  substances  induced  by  an  intentional  innocuous 
modification  of  the  disease.  The  dream  of  medical 
science  has  been  to  manufacture  these  natural  products 
in  the  test  tube,  but  so  far  this  dream  has  not  been 
realized.  In  the  case  of  certain  bacteria,  —  most 
notably  diphtheria,  tetanus,  and  a  few  others  —  which 
have  certain  peculiarities  so  that  they  lend  themselves 
particularly  for  this  purpose,  —  these  antagonistic 
properties  have  been  secured  in  marked  concentration 
in  the  blood  of  animals,  —  usually  horses.  The  use 
of  the  acquired  antitoxin  in  human  beings  is  hardly 
feasible  as  it  would  require  the  use  of  too  large  an 
amount  of  blood  to  afford  adequate  antagonistic  sub- 
stances. Horses,  however,  can  be  so  highly  immunized 
that  a  small  portion  of  the  blood  serum  (the  residual 
fluid  after  the  clotting  of  blood)  contains  sufficient 
antitoxin  to  counteract  all  the  toxins  in  the  entire 
human  body.  Since  toxins  and  antitoxins  are  usually 
inert  when  given  by  the  mouth,  the  horse  serum  which 
contains  the  antitoxin  must  be  administered  either 
under  the  skin  or  into  a  vein.  Unfortunately,  so  far, 
we  have  not  been  able  to  develop  antitoxins  for  many 
bacteria.  The  antitoxin  may  be  used  to  prevent  as 
well  as  to  cure  disease.  The  effects  of  antitoxins  are 
transitory,  lasting  in  the  case  of  diphtheria  only  from 
two  to  six  weeks.  The  antitoxin  created  for  one  disease 
acts  only  against  the  toxin  of  that  disease. 

Bactericidal  Substances.  In  addition  to  endeavoring 
to  produce  antitoxin,  scientists  have  labored  to  produce 
bactericidal  substances.  Antimeningitis  serum,  which 
has  been  highly  successful,  probably  acts  more  in  antag- 
onizing the  bacteria  and  the  contained  products  than 
in  antagonizing  the  doubtful  diffusible  toxin  of  the 
meningococcus.  But  at  present  medical  research  is 
turning  more  to  chemical  substances  than  to  biological 
substances  in  the  hope  of  obtaining  bactericidal  agents. 


THE  COMMUNICABLE  DISEASES       175 

It  has  long  been  known  that  quinine,  for  example, 
would  kill  certain  animal  parasites,  but  that  it  did  not 
seriously  affect  the  body  tissues.  The  ordinary  dis- 
infectants, however,  cannot  be  used  to  kill  micro- 
organisms in  the  body,  since  they  destroy  the  body 
cells  as  well  as  the  infecting  agents.  The  painstaking 
labors  of  Ehrlich  gave  us  Salvarsan,  a  substance  that 
has  a  destructive  affinity  for  the  spirochsetse  of  syph- 
ilis, but  which,  as  a  rule,  does  not  injure  the  body. 
The  spirochsetse  are  an  unusual  form  of  bacteria  and 
are  probably  more  related  to  the  animal  parasites. 
Still  a  beginning  has  been  made  and  such  chemotherapy 
promises  much  for  the  future.  Of  much  less  impor- 
tance, but  still  of  significance,  is  the  earlier  discovery 
that  formaldehyde  in  certain  combinations,  such  as  the 
patented  urotropin,  could  be  taken  into  the  body  and 
the  formaldehyde  liberated  and  thus  act  as  a  disin- 
fectant. Thus,  under  favorable  conditions,  some  bac- 
teria which  infect  the  kidney  and  bladder  are  killed. 

While  we  do  possess  certain  antagonistic  substances 
which  act  in  a  remarkably  effective  manner,  like  diph- 
theria antitoxin,  antimeningitis  serum,  and  Salvarsan, 
in  most  instances  of  bacterial  disease  we  are  thrown  back 
on  the  natural  creation  of  resistance.  We  have  learned 
that  insufficient  and  improper  food,  excessive  fatigue 
from  any  cause,  alcoholism  and  other  poisonings,  and, 
in  fact,  any  misuse  of  the  body  or  its  functions  carry 
with  them  the  penalty  of  reduced  resistance  to  com- 
municable disease.  Poverty  with  its  attendant  ills 
can  be  demonstrated  to  increase  the  susceptibility  to 
disease.  The  greatest  natural  resistance  to  communi- 
cable diseases  is  found  in  the  maintenance  of  health 
through  the  exercise  of  the  principles  of  sound  hygiene. 

Methods  of  Spread  of  Communicable  Disease.  The 
prevention  of  disease,  and  especially  of  the  communi- 
cable diseases,  is  so  manifestly  desirable  as  to  be  self- 


176  HEALTH  AND  DISEASE 

evident.  As  we  have  seen,  we  are  able  at  present  to 
guarantee  a  cure  in  few  of  the  communicable  diseases. 
Of  course,  in  most  instances,  the  victim  of  such  diseases 
recovers,  but  this  is  largely  due  to  the  natural  forces  of 
the  body  and  only  in  a  slight  measure  to  specific  treat- 
ment. Furthermore,  since  from  their  nature  communi- 
cable diseases  do  not  originate  de  novo,  but  are  trans- 
ferred from  one  person  to  another,  either  directly  or 
indirectly,  each  case  of  such  a  disease  represents  an 
additional  focus  with  the  manifold  possibilities  of 
further  dissemination  of  disease.  With  few  exceptions 
the  primary  focus  of  communicable  disease  is  man,  for 
the  infected  man  is  the  starting  point  for  the  spread  of 
such  infections. 

In  order  effectually  to  prevent  the  spread  of  disease, 
it  is  necessary  to  know  as  much  as  possible  about  the 
habits  of  the  infecting  micro-organisms,  for  the  pre- 
vention of  communicable  disease  depends  primarily 
on  the  knowledge  of  the  methods  by  which  that  disease 
is  communicated  from  person  to  person.  Prevention 
is  successful  only  in  proportion  to  the  completeness 
of  the  interruption  of  the  line  of  communication. 
Theoretically  all  communicable  diseases  are  prevent- 
able, but  practically  we  find  it  difficult  to  interrupt  the 
line  of  communication  in  some  diseases.  In  other 
diseases,  where  we  do  not  know  the  method  of  dissemina- 
tion, we  work  blindly  and,  consequently,  ineffectually. 

Obviously  the  method  of  communication  of  disease 
determines  the  method  of  prevention.  For  example, 
as  long  as  yellow  fever  was  considered  a  filth  disease 
and  spread  through  the  human  secretions  or  by  con- 
tact, the  most  elaborate  precautions  had  no  effect  on 
its  spread  for  it  is  carried  only  by  a  mosquito. 

The  manner  in  which  communicable  diseases  are 
transferred  from  person  to  person  and  gain  entrance  to 
the  body  gives  us  a  working  classification  of  these 


THE  COMMUNICABLE  DISEASES       177 

diseases.  No  classification  is  entirely  satisfactory. 
In  many  instances  usage  has  given  a  new  meaning  to 
words  which,  from  their  derivation,  mean  something 
quite  different.  The  words  "  contact  ",  "contagion  ", 
and  "  contagious  "  afford  a  good  illustration.  Contact 
originally  meant  touch.  Yet  we  speak  of  contact 
cases  of  diphtheria,  merely  meaning  rather  directly 
from  one  person  to  another  through  the  air.  We  speak 
of  contact  cases  of  typhoid,  meaning  that  persons 
handling  typhoid  discharges,  not  necessarily  touching 
the  patient,  have  contracted  the  disease.  We  also 
speak  of  indirect  contact.  Contagious  is  now  used 
fairly  generally  as  synonynous  with  communicable. 

The  communicable  diseases  may  be  divided  roughly 
into  five  classes :  (1)  those  that  are  ingested  and  enter 
the  body  through  the  digestive  tract,  usually  in  connec- 
tion with  food  and  drink,  —  the  method  of  ingestion ; 
(2)  those  that  are  spread  in  the  air,  usually  in  the  form 
of  droplets,  and  enter  the  body  through  the  air  passages, 
the  air-borne  diseases ;  (3)  those  that  are  spread  by 
contact  and  gain  entrance  at  the  site  of  the  inoculation 
through  the  skin ;  (4)  those  that  are  spread  by  insects, 
and  (5)  those  whose  manner  of  gaining  entrance  to  the 
body  is  unknown.  When  a  disease  is  spread  by  only 
one  method,  which  is  the  general  rule,  our  preventive 
precautions  need  only  be  directed  against  that  line  of 
communication.  But  some  diseases  are  spread  by 
more  than  one  method  and  this  necessitates  various 
precautions.  Quarantine  and  isolation  merely  signify 
that  the  necessary  precautions  are  being  taken  for  the 
prevention  of  the  communication  of  some  particular 
disease  and  must  obviously  vary  with  each  disease. 

Considerable  confusion  inevitably  results  from  the 
use  of  any  classification.  It  is  necessary  to  emphasize 
that  bacteria  locked  up  in  an  infected  person  are  inoc- 
uous  to  others.  Disease  is  spread  when  bacteria  have 


178  HEALTH  AND  DISEASE 

a  means  of  escape.  Consequently  the  nature  of  the 
disease,  the  avenues  afforded  the  bacteria  to  escape, 
the  number  of  bacteria  that  so  escape  from  the  diseased 
persons  plus  the  viability  of  the  bacteria  in  the  partic- 
ular medium,  usually  a  secretion  or  discharge,  under 
the  given  conditions  determine  how  infectious  a  diseased 
person  —  the  bacteria  carrier  —  is.  So  it  follows 
naturally  that  all  diseases  are  not  equally  communi- 
cable even  within  any  group  and  some  knowledge  of 
the  various  diseases  is  necessary  to  prevent  their  spread. 


CHAPTER  XI 

DISEASES  TRANSMITTED  BY  INGESTION 

Typhoid  Fever 

Prevalence  of  Typhoid  Fever.  First  in  importance 
among  the  diseases  caused  by  ingestion  is  typhoid  fever. 
This  disease  ranks  fourth  in  causing  deaths  in  the 
United  States,  being  exceeded  only  by  tuberculosis, 
pneumonia,  and  cancer.  Bright's  disease,  diarrhea 
and  enteritis,  apoplexy,  and  arterial  disease,  all  cause 
more  deaths  than  typhoid  fever,  but  these  conditions 
must  be  regarded  as  disease  groups  and  not  as  single 
diseases.  In  1914,  typhoid,  diabetes,  and  diphtheria, 
including  croup,  all  caused  about  the  same  number  of 
deaths.  The  same  statistics  show  a  gratifying  de- 
crease of  fifty-seven  per  cent  over  the  figures  for  the 
year  1900.  Nevertheless  there  is  still  more  typhoid 
fever  to-day  per  capita  in  the  United  States  than  there 
was  ten  years  ago  in  Germany  and  England.  Ten 
years  ago  the  United  States  had  several  times  as  much 
typhoid  as  those  countries  in  proportion  to  population. 
As  typhoid  is  due  almost  entirely  to  neglect  of  sanitary 
conditions,  which  in  a  large  measure  could  be  prevented, 
the  presence  of  this  disease  to  the  extent  of  over  150,000 
cases  with  a  mortality  of  25,000  annually  is  a  severe 
reflection  upon  our  national  methods  of  health  protec- 
tion. The  incidence  of  typhoid  fever  in  a  community, 
as  Sir  William  Osier  pointed  out,  can  be  taken  as  the 
index  of  the  sanitary  intelligence  of  that  community. 

179 


180  HEALTH  AND  DISEASE 

The  name  "  typhoid  fever  "  comes  from  the  Greek 
word  meaning  stupor  as  does  the  word  "  typhus  ", 
another  disease  characterized  by  stupor  and  which 
was  long  confused  with  typhoid.  In  fact,  although 
typhoid  fever  has  been  known  even  from  traditional 
times,  it  has  been  distinguished  from  typhus  only 
recently.  In  1829,  Louis,  of  Paris,  first  emphasized  a 
number  of  cardinal  points  of  typhoid,  but  not  until 
1837  was  the  identification  completed  by  Gerhard  of 
Philadelphia.  In  1880  Eberth  isolated  the  bacillus 
of  the  disease  and  proved  it  to  be  the  sole  cause.  So 
far  it  has  been  impossible  to  produce  typhoid  in  ani- 
mals. 

Typhoid  is  found  to  some  degree  all  over  the  world, 
but  it  is  unduly  prominent  in  the  United  States.  It 
is  the  cause  in  the  large  majority  of  cases  of  continuous 
fevers  of  more  than  ten  days'  duration  in  the  temperate 
zone.  The  disease  has  sometimes  been  called  "  slow  " 
fever,  and  again  it  has  been  known  by  the  name  of  the 
locality  in  which  it  existed,  as  Mediterranean  fever. 

Course  of  Typhoid  Fever.  In  the  course  of  typhoid 
fever,  the  bacillus  is  found  in  the  blood  and  in  the 
feces.  It  is  usually  easier  to  diagnose  the  disease  from 
the  blood.  Another  method  of  diagnosis  depends  upon 
a  certain  reaction  in  the  blood  —  the  Widal' reaction. 
Widal  found  that  a  drop  of  blood  from  a  person  who 
has  typhoid  or  who  has  had  it  recently,  when  mixed 
with  the  typhoid  bacilli,  will  cause  the  bacilli  to  come 
together  and  will  prevent  their  moving  about.  Ob- 
viously something  has  been  developed  in  the  blood 
which  not  only  kills  the  bacilli  but  clumps  them.  Un- 
doubtedly this  phenomenon  plays  a  large  part  in  the 
protection  against  the  disease.  The  blood  of  a  person 
who  has  not  had  typhoid  will  not,  in  this  blood  test, 
show  any  effect  on  the  bacilli. 

One  attack  of  typhoid  protects  reasonably  for  the 


DISEASES  TRANSMITTED  BY  INGESTION  181 

rest  of  one's  life.  There  are,  however,  occasional 
cases  where  an  individual  has  had  typhoid  more  than 
once,  but  most  of  these  cases  are  extremely  doubtful 
and  they  hark  back  to  the  days  when  diagnoses  were 
not  accurate. 

Much  of  the  importance  of  typhoid  fever  is  due  to 
the  fact  that  it  attacks  people  in  the  bloom  of  life,  a 
large  percentage  of  the  cases  occurring  between  the 
ages  of  twenty-five  and  thirty.  The  disease  is  mild 
in  children  and  old  people,  while  it  is  more  liable  to  be 
fatal  in  young  adult  life.  The  mortality  varies  under 
different  conditions,  but  the  average  mortality  is  be- 
tween eight  and  sixteen  per  cent. 

Typhoid  fever  is  a  long  fever  and  may  last  for  months. 
When  it  has  run  its  course,  the  patient  is  left  extremely 
weak.  In  the  United  States  Army  the  man  who  has 
typhoid  is  automatically  given  a  six  months'  furlough 
to  convalesce.  So  the  importance  of  typhoid  fever 
is  not  only  that  it  kills  so  many  people,  but  also  that 
it  is  the  cause  of  immense  economic  loss  in  that  it 
carries  with  it  such  a  long  period  of  economic  inactivity 
during  the  most  productive  years. 

Typhoid  fever  is  much  more  common  in  certain 
localities  than  in  others.  The  cities  along  the  Great 
Lakes  and  on  rivers,  as  Philadelphia,  have  had  severe 
epidemics  of  typhoid.  On  the  other  hand,  typhoid 
fever  is  almost  unknown  in  Germany,  and  the  mortality 
in  Berlin  and  Munich  is  almost  nothing.  In  fact  in 
all  the  large  European  cities  typhoid  is  much  less 
common  than  in  the  United  States,  although  it  is 
usually  rather  prevalent  in  Italy  and  Russia. 

Typhoid  fever  is  a  so-called  self-limited  disease. 
Left  to  itself  typhoid  will  run  its  course  and  a  certain 
percentage  of  the  cases  will  die.  If  the  patient  is  not 
well  cared  for,  the  mortality  will  be  high,  perhaps  as 
high  as  fifty  per  cent.  The  disease  stops  on  account 


182  HEALTH  AND  DISEASE 

of  the  natural  protection  of  the  body.  There  is  as  yet 
no  real  cure  for  typhoid,  and,  therefore,  all  our  meas- 
ures must  be  aimed  at  the  prevention  of  the  disease. 

Transmission  of  Typhoid  Fever.  Since  typhoid 
fever  often  occurs  in  epidemics  of  different  origin,  it 
is  impossible  to  give  accurate  differentiating  accounts 
of  its  transmission.  All  the  excretions  of  the  typhoid 
fever  patient  contain  the  typhoid  bacilli  and  the  spread 
of  the  disease  is  through  the  spread  of  these  excreta. 
It  is  a  conservative  statement  that  forty  per  cent  of 
the  cases  are  due  to  contaminated  water ;  twenty- 
five  per  cent  to  infected  milk,  and  thirty  per  cent  to 
contaminated  substances  put  into  the  mouth,  includ- 
ing those  contaminated  by  fly  transmission.  But 
water  is  the  great  carrier  of  typhoid,  —  milk  is  often 
inf ected  from  water  —  and  the  number  of  typhoid 
cases  is  an  excellent  test  of  a  city  water  supply. 

Water  may  be  contaminated  in  various  ways.  The 
essential  fact  is  the  mixture  of  sewage  and  water. 
On  a  small  scale,  we  have  the  household  well  con- 
taminated from  the  near-by  privy.  On  a  large  scale 
we  have  the  community  water  supply  infected  from  the 
sewage  of  another  community.  In  the  early  stages 
of  the  disease,  a  person  is  often  ambulatory  while 
having  the  bacteria  in  his  stools,  and,  in  fact,  the  ex- 
ceptional case  may  be  ambulatory  throughout.  Again, 
we  know  that  a  proportion  of  the  recovered  cases 
carry  bacteria  in  their  stools  for  years.  These  facts 
suggest  how  easily  a  water  supply  may  be  infected 
and  how  necessary,  even  in  the  apparent  absence  of 
disease,  are  good  sanitary  habits  on  the  part  of  the 
individual  and  careful  disposal  of  sewage  and  purifi- 
cation of  the  water  supply  on  the  part  of  the  com- 
munity. 

Typhoid  is  also  transmitted  in  food,  and  milk  is  the 
principal  food  which  acts  as  a  carrier  of  the  disease. 


DISEASES  TRANSMITTED  BY  INGESTION  183 

This  is  due  to  the  fact  that  as  soon  as  the  typhoid 
bacillus  gets  into  milk,  it  finds  a  perfect  medium  for 
growth.  If  the  temperature  of  the  milk  is  kept  low, 
the  organisms  will  grow  but  slowly.  This  entrance 
of  the  typhoid  bacillus  into  the  milk  may  occur  through 
water  or  through  careless  handling,  but  it  usually 
enters  in  the  water  supply  in  washing  out  the  cans 
and  in  similar  operations.  Cows  never  have  typhoid 
fever,  so  it  follows  that  the  milk  must  be  contaminated 
from  human  sources.  When  milk  is  contaminated,  it 
carries  the  bacilli  in  large  quantities,  but  epidemics  due 
to  milk  are  usually  mild. 

Oysters  are  also  carriers  of  typhoid  fever.  This  is 
usually  due  to  the  now  forbidden  practice  of  fattening 
oysters  in  a  place  where  sewage  is  discharged  into  the 
ocean.  If  there  are  pathogenic  organisms  in  the 
sewage,  an  epidemic  may  occur. 

Typhoid  bacilli  cannot  live  for  any  length  of  time 
in  ice,  but  a  few  epidemics  of  typhoid  fever  have  been 
traced  to  ice  made  from  contaminated  water. 

The  importance  of  flies  in  disease  seems  to  have  been 
exaggerated.  If  garbage  and  sewage  were  taken  care 
of  and  thus  no  contaminated  food  left  for  the  flies, 
there  would  be  no  danger  from  them.  There  is  no 
excuse  for  leaving  typhoid-containing  substances  ex- 
posed to  flies.  It  is  quite  possible  for  flies  to  carry 
typhoid  bacilli  from  the  excretions  to  food,  and  flies 
certainly  seem  to  be  a  definite  factor  in  the  spread  of 
typhoid  fever. 

Another  source  of  typhoid  infection  of  water  and 
particularly  of  food  has  been  found  recently  in  the 
typhoid  carrier.  After  a  person  has  had  typhoid 
fever  and  is  perfectly  well,  about  five  per  cent  of  the 
cases  continue  for  many  years  to  carry  the  germs  of  the 
disease  in  their  stools.  "  Typhoid  Mary  "  is  a  typical 
illustration  of  a  typhoid  carrier. 


184  HEALTH  AND  DISEASE 

"  Typhoid  Mary "  was  a  cook  and  a  somewhat 
itinerant  one,  so  that  a  number  of  typhoid  epidemics 
were  traced  to  her.  Usually  the  typhoid  bacilli  got 
into  the  food.  A  great  amount  of  misplaced  sympathy 
has  been  wasted  on  her,  since  it  was  necessary  for  her 
to  commit  the  sanitary  crime  of  introducing  (uncon- 
sciously, of  course)  by  her  filthy  habits  particles  of 
her  feces  into  the  food.  That  such  habits  are  not 
uncommon  is  shown  by  a  considerable  number  of  food 
epidemics  of  typhoid  traced  to  carriers  who  were  cooks. 
All  this  illustrates  the  importance  of  cleanly  habits 
among  people  who  handle  food  that  is  not  to  be  heated 
subsequently  to  such  a  degree  that  the  bacteria  will 
be  killed. 

Any  one  who  handles  a  typhoid  fever  patient  or  any 
of  the  excreta  of  a  typhoid  fever  patient  or  carrier  may 
carry  the  bacteria  into  his  mouth  in  various  ways. 
He  may  even  infect  a  limited  amount  of  food.  The 
neglect  of  scrupulous  cleanliness  of  the  hands  has 
been  the  cause  of  a  considerable  number  of  cases  of 
typhoid  fever  among  doctors,  nurses,  and  others  who 
have  handled  typhoid  material. 

Typhoid  Fever  and  War.  Much  of  our  knowledge 
of  the  prevention  of  typhoid  fever  has  been  gained 
through  our  tragic  experiences  with  the  disease  in 
wars.  Typhoid  has  always  played  an  important  part 
in  wars  so  that  it  has  been  said  that  an  army  has  two 
enemies  :  bacilli  and  bullets.  In  our  Civil  War  in  the 
Northern  Army  there  were  75,361  cases  of  typhoid 
fever  with  27,056  deaths  among  the  white  troops,  and 
4,094  cases  and  2,280  deaths  among  the  colored  troops. 
In  the  Franco-Prussian  War,  among  the  German 
troops  there  were  73,396  cases  with  8,789  deaths 
from  typhoid,  representing  sixty  per  cent  of  the  total 
mortality.  The  incidence  to  total  strength  was  very 
high.  There  was  typhoid  fever  in  every  corps  of  the 


DISEASES  TRANSMITTED  BY  INGESTION  185 

army  at  the  beginning  of  the  war.  Two  factors  influ- 
enced the  prevalence  of  the  disease :  the  troops  carried 
the  infection  with  them,  and  they  were  campaigning 
in  a  country  in  which  typhoid  fever  was  common. 
In  the  Afghan  War  of  1878-80  the  troops  brought 
the  disease  with  them  from  infected  areas  in  India, 
and  it  was  carried  to  localities  where  it  had  been 
unknown  previously.  In  the  Boer  War  there  were 
57,684  cases  of  typhoid  fever  and  8,022  deaths  in  the 
British  army. 

Probably  the  worst  lesson  on  typhoid  fever  was 
received  by  the  United  States  in  the  Spanish- American 
War.  The  highest  incidence  of  the  disease  was  among 
the  men  who  never  left  the  United  States  but  who 
went  into  encampments.  Among  107,973  men  there 
were  20,738  cases  of  typhoid  fever  with  1,580  deaths 
within  six  months.  In  the  volunteer  regiments  ninety 
per  cent  of  the  men  who  had  typhoid  fever  contracted 
it  within  eight  weeks  after  going  into  camp  and  these 
epidemics  were  as  marked  in  the  North  as  in  the  South. 

Thus  typhoid  fever  in  war  frequently  killed  far  more 
than  the  bullets  of  the  enemy.  Moreover  thousands 
of  soldiers  died  of  the  disease  before  they  even  saw  the 
enemy.  A  well-known  surgeon  relates  how  he  entered 
the  Medical  Corps  of  the  Army  for  the  surgical  expe- 
rience. He  had  visions  of  a  vast  number  of  serious 
operations,  amputations,  and  the  like.  On  the  con- 
trary his  experience  consisted  of  the  care  of  several 
thousand  cases  of  typhoid  fever  and  one  trivial  case 
of  bullet  wound. 

In  addition  to  the  knowledge  gained  by  these  tragic 
experiences,  a  second  factor  in  reducing  and  almost 
eliminating  typhoid  fever  in  war  has  been  the  typhoid 
inoculation.  In  1896,  almost  simultaneously,  Pfeiffer 
and  Kolle  in  Germany  and  Wright  in  England  published 
the  results  of  experiences  in  the  prevention  of  typhoid 


186  HEALTH  AND  DISEASE 

fever  by  vaccination  with  the  bacillus  typhosus  killed 
by  heat. 

One  difficulty  which  the  sanitary  experts  of  the 
armies  had  to  face  was  that  the  etiology  of  typhoid 
fever  differs  somewhat  in  civil  and  in  military  life. 
There  are  several  reasons  for  this.  In  the  first  place 
in  military  encampments  there  is  a  greater  difficulty 
in  disposing  of  excreta  due  to  overcrowding  and  the 
unusual  conditions.  This  leads  to  infection  in  such 
various  ways  as  the  contamination  of  the  water  supply, 
or  the  bacilli  may  be  blown  about  or  carried  by  flies. 
The  close  contact  of  men  crowded  together  favors 
direct  infection,  while  clothing,  blankets,  and  tents 
may  be  contaminated.  Then,  too,  there  are  usually 
inadequate  facilities  for  ordinary  cleanliness.  The 
influence  of  camp  life  on  troops  who  had  a  good  water 
supply  was  shown  at  Jacksonville,  Florida,  in  the 
fall  of  1898.  There  were  about  30,000  people  in  the 
city  and  few  cases  of  typhoid,  while  among  the  troops 
nearby,  with  the  same  water  supply,  the  disease  was 
prevalent. 

The  Russo-Japanese  War  was  the  first  in  which  the 
lessons  of  previous  wars  and  the  surer  knowledge  of 
how  typhoid  is  spread  began  to  bear  fruit.  Medical 
men  were  utilized  to  prevent  disease  as  well  as  to  treat 
it,  with  the  result  that  the  mortality  from  typhoid 
fever  was  reduced  tremendously  below  what  it  had 
ever  been  in  a  previous  war. 

In  the  European  War  typhoid  fever,  especially  on 
the  Western  Front,  has  been  rare.  This  is  due  to  the 
absolute  sanitary  control  in  the  camps  and  to  typhoid 
inoculation.  The  relative  importance  of  these  meas- 
ures is  not  entirely  clear.  It  seems  probable  that 
sanitary  control  is  by  far  the  more  important  since  it 
eliminates  not  only  the  typhoid  micro-organisms,  but 
all  other  micro-organisms  as  well.  The  value  of  the 


DISEASES  TRANSMITTED  BY  INGESTION  187 

typhoid  vaccination,  more  properly  inoculation,  seems 
to  be  in  the  additional  protection  against  the  almost 
inevitable  lapses  of  sanitary  control. 

The  sanitary  practice  in  war  now  involves  a  number 
of  considerations.  Great  care  is  taken  in  the  selection 
of  the  camp  sites.  Strict  regulations  govern  the  dispo- 
sal of  sewage.  Personal  cleanliness  is  insisted  upon. 
The  danger  from  flies,  which  was  shown  to  be  very 
real  in  the  Boer  War,  is  removed.  Garbage  is  burned 
and  all  food  is  screened  so  that  flies  cannot  get  at  the 
food.  The  water  supply  is  such  an  important  consid- 
eration that  it  is  examined  frequently.  No  water  is 
permitted  to  be  drunk,  except  under  the  sanction  of 
the  officers.  If  a  man  drinks  water  outside,  he  must 
boil  or  otherwise  disinfect  it.  Mobile  laboratories 
facilitate  the  diagnosis  of  all  cases  of  fever,  besides 
testing  all  who  handle  food  for  typhoid  carriers. 

Typhoid  Vaccination  or  Inoculation.  The  amount 
of  protection  which  the  typhoid  vaccination  affords 
has  been  worked  out  in  the  United  States  Army.  Out 
of  a  group  of  60,000  men  who  were  vaccinated,  there 
have  been  only  twelve  cases  and  no  deaths  over  a 
period  of  three  years.  This  vaccination  is  probably 
not  entirely  effective  against  a  tremendous  dose  of 
typhoid  bacilli.  In  a  large  epidemic,  some  of  the 
people  who  have  received  inoculation  will  be  sick,  but 
only  mildly,  and  a  fatal  case  of  typhoid  after  inocula- 
tion is  extremely  rare.  Of  course,  it  is  also  true,  as  it 
is  in  smallpox  vaccination,  that  some  people  do  not 
receive  protection,  because  the  vaccination  or  inocu- 
lation does  not  '*  take."  The  duration  of  the  protec- 
tion after  typhoid  vaccination  is  not  so  long  as  that 
afforded  by  an  attack  of  the  disease,  which  is  usually 
for  life.  It  is  desirable  that  the  vaccination  be  re- 
peated after  two  to  three  years  and  a  third  time  after 
the  same  interval. 


188  HEALTH  AND  DISEASE 

Typhoid  vaccine  is  prepared  as  follows.  The  typhoid 
bacilli  are  heated  to  55-60°  C.  or  140°  F.  for  half  an 
hour.  This  temperature  is  sufficient  to  kill  the  organ- 
isms, but  some  of  the  poisons  of  the  bacilli  will  be  found 
in  the  solution.  If  a  certain  number  of  these  bacilli 
are  injected  beneath  the  skin  of  an  individual,  he  will 
not  get  typhoid  fever,  but  he  will  be  slightly  poisoned 
by  the  dead  bacilli  so  that  the  defensive  apparatus  of 
the  body  will  come  into  action  and  will  produce  a  large 
number  of  substances  which  will  fight  off  the  poisons. 
This  dose  of  vaccine  is  repeated  two  or  three  times. 
After  these  inoculations,  the  person's  blood  will  give 
the  same  Widal  reaction  as  that  of  a  person  who  has 
had  typhoid  fever.  The  vaccination  causes  a  slight 
inconvenience  in  a  small  percentage  of  cases,  but  no 
serious  illness,  and  the  return  in  the  protection  against 
typhoid  fever  is  considerable. 

Typhoid  fever  is  a  preventable  disease  depending 
upon  the  sanitary  cooperation  of  the  individual  and 
the  community.  The  community  can  guarantee  the 
safe  disposal  of  sewage  and  an  uncontaminated  water 
supply.  The  individual  must  cultivate  sanitary  per- 
sonal habits,  especially  in  regard  to  the  excreta  of 
himself  and  others.  Every  case  of  typhoid  should  be 
examined  after  recovery  for  the  purpose  of  discovering 
typhoid  carriers.  Those  who  handle  food,  which  is  a 
good  culture  medium  for  bacteria,  which  is  not  subse- 
quently heated,  should  be  examined  for  typhoid  car- 
riers. Those  who  handle  food  should  observe  the 
strictest  cleanliness.  We  cannot  assume  that  cooks 
who  are  typhoid  carriers  are  peculiarly  uncleanly  in 
their  habits.  The  correct  assumption  is  that  it  is 
far  easier  than  was  formerly  believed  to  contaminate 
food.  The  indication  is  certainly  plain  that  the  estab- 
lishment of  the  custom  and  the  facilities  for  thorough 
hand  washing  is  necessary,  Food  and  excreta  should 


DISEASES  TRANSMITTED  BY  INGESTION  189 

not  be  exposed  to  flies.  By  taking  all  the  above- 
mentioned  precautions  typhoid  fever  can  be  elimi- 
nated. Finally,  it  should  be  emphasized  again  that 
water  is  the  great  carrier  of  typhoid  fever  and  that 
until  all  the  communities  of  the  United  States  safe- 
guard their  water  supplies  as  do  the  cities  with  few 
cases  of  typhoid  fever,  there  still  will  be  cases  of  the 
disease  and  typhoid  carriers. 

Para-Typhoid  Fever.  There  are  a  number  of  dis- 
eases and  an  equal  number  of  causative  bacteria  which 
are  similar  to  typhoid  and  its  bacterium.  These  are 
known  as  the  para-typhoid  fevers,  although  such 
fevers  are  rare  in  comparison  with  real  typhoid  fever. 
Such  fevers  are  apparently  slight  deviations  from 
typhoid  fever  and  the  difference  is  only  slight.  Para- 
typhoid fevers  are  caused  by  the  same  conditions  as 
typhoid.  In  the  European  War  there  has  been  a 
considerable  amount  of  para-typhoid.  This  suggests 
that  even  under  good  sanitary  conditions  typhoid 
fever  would  have  existed  had  it  not  been  for  the 
effective  preventive  inoculations.  The  same  sanitary 
precautions  are  effective  against  para-typhoid  as 
against  typhoid  fever. 

Asiatic  Cholera 

In  its  transmission  and  its  prevention  Asiatic  cholera 
corresponds  closely  to  typhoid  fever.  Like  typhoid, 
cholera  is  always  caused  by  an  ingestion  of  the  infect- 
ing micro-organisms  in  the  alimentary  tract.  There 
are  also  carriers  of  cholera  as  in  typhoid.  Cholera 
also  causes  a  diarrhea,  and  organisms  of  the  disease 
are  found  in  enormous  numbers  in  the  stool.  The 
disease  is  caused  by  a  specific  bacterium,  a  spirillum, 
which  was  discovered  by  Koch.  Again,  as  with  ty- 
phoid, proper  sanitation  can  eliminate  cholera. 


190  HEALTH  AND  DISEASE 

It  is  probable  that  cholera  has  occurred  for  many 
centuries,  but  it  is  noteworthy  that  unlike  most  epi- 
demics of  pronounced  characteristics  and  high  mor- 
tality, no  clear  description  of  its  presence  was  placed 
on  record.  Asiatic  cholera  is  not  a  disease  of  special 
moment  in  this  country  as  it  is  primarily  a  disease  of 
the  Tropics.  Epidemics  start  along  the  Ganges  River, 
for  cholera  is  always  present  in  India,  and  then  sweep 
over  Asia  and  into  Europe  in  recurring  cycles.  When- 
ever an  epidemic  reaches  Europe  a  few  sporadic  cases 
usually  reach  the  United  States.  During  the  first 
three  centuries  after  the  discovery  of  India,  cholera 
visited  Europe  on  several  occasions  but  the  first  real 
outbreak  was  in  1564.  However,  prior  to  1817, 
cholera  was  confined  to  certain  parts  of  India  and  never 
permanently  infected  districts  far  removed  from  there. 

Since  1817,  when  an  epidemic  of  unusual  severity 
broke  out  in  India,  cholera  has  been  constantly  pres- 
ent in  endemic  form  in  some  parts  of  that  country 
and  has  been  carried  thence  by  pilgrims  or  travelers 
or  by  their  possessions.  Many  parts  of  the  world 
have  suffered  from  the  disease,  and  seven  distinct  inva- 
sions of  Europe  have  occurred,  the  latest  being  from 
1891  to  1895.  In  1893  Hamburg  suffered  a  severe 
epidemic  of  cholera  which  was  due  to  the  pollution  of 
the  water  supply.  No  distinct  epidemic  of  cholera  has 
occurred  in  the  United  States  since  1873. 

The  native  East  Indian,  a  rather  filthy  person,  is 
apt  to  drink  out  of  the  same  water  in  which  he  has  not 
only  bathed,  but  also  into  which  the  wastes  from  his 
body  have  passed.  The  stool  is  rich  in  bacteria  and 
the  water  is  bound  to  be  polluted.  As  the  prevention 
of  the  disease  depends  practically  entirely  on  the  intel- 
ligence of  the  people  and  the  cooperation  of  the  natives 
in  keeping  to  the  standards  of  sanitation,  the  disease 
still  continues.  In  traveling  in  the  cholera  countries, 


DISEASES  TRANSMITTED  BY  INGESTION  191 

therefore,  it  is  important  to  exercise  eternal  vigilance. 
Cholera  has  been  a  great  menace  to  armies,  especially 
to  armies  working  in  the  Tropics  during  the  summer. 
Cholera  has,  apparently,  been  prevalent  on  the  East- 
ern Front  during  the  European  War,  particularly  in 
Turkey  and  in  Asia. 

Cholera  can  be  prevented  only  by  community  sani- 
tation. Since  the  immunity  conferred  by  the  disease 
is  relatively  short,  the  use  of  a  cholera  vaccine  confers 
only  a  temporary  protection.  In  Japan  it  has  been 
the  experience  that  in  times  of  epidemic  a  vaccine 
was  of  some  prophylactic  value.  The  vaccine  may 
also  be  of  value  to  armies  on  the  march,  but  in  general 
the  protection  afforded  by  vaccine  is  slight. 

There  is  no  specific  cure  for  cholera.  Under  proper 
medical  treatment  the  disease  is  not  anywhere  near  so 
fatal  as  terrible  epidemics  which  have  a  tremendously 
high  mortality,  for  only  about  twenty-five  per  cent  of 
the  cases  die.  Cholera,  like  typhoid  fever,  runs  a 
perfectly  definite  course  and  the  patient,  if  he  survives, 
gets  entirely  well.  About  six  or  seven  per  cent  of  the 
recovered  cases  are  cholera  carriers.  The  longest 
period  during  which  they  carry  the  infecting  micro- 
organisms is  six  months,  but  only  rarely  does  this 
period  extend  over  twenty  days. 

Other  Diseases  Spread  by  Ingestion 

Dysentery.  There  are  a  few  other  diseases,  of 
rather  less  importance,  which  are  transmitted  in  the 
same  way  as  typhoid  fever,  para-typhoid,  and  cholera. 
One  fairly  large  group  is  grouped  under  the  term 
dysentery. 

Under  the  general  heading  of  dysentery  we  are  apt 
to  include  all  forms  of  severe  diarrhea  of  any  duration, 
particularly  when  associated  with  fever.  There  are 


192  HEALTH  AND  DISEASE 

at  least  two  closely  allied  bacilli,  somewhat  similar 
to  the  typhoid  bacillus,  which  cause  a,  definite  disease 
which  can  only  be  diagnosticated  by  the  blood  tests 
and  the  finding  of  the  causative  organisms  in  the 
stools.  Every  summer  sees  a  few  cases  of  this  bacillary 
dysentery,  a  disease  which  tends  to  be  self-limited.  It 
may  become  epidemic  in  armies  or  wherever  people 
are  crowded  together  in  unsanitary  conditions  in 
Temperate  zones  as  well  as  in  the  Tropics.  The  pre- 
vention consists  of  the  same  sanitary  regulations  which 
are  effective  against  typhoid  fever. 

In  addition,  we  have  a  second  specific  type  of  dysen- 
tery, due  to  an  amoeba  or  an  animal  form  of  life. 
These  amoebae  live  in  water  and  in  vegetables  and 
fruit.  Amoebic  dysentery  is  never  epidemic,  but 
occurs  as  a  more  or  less  chronic  condition  with  serious 
sequelae.  Amoebic  dysentery  is  a  common  disease 
of  the  Tropics,  and  we  are  now  beginning  to  recognize 
a  considerable  number  of  cases  in  the  Temperate  zone. 
In  the  early  stages,  at  least,  treatment  with  ipecac, 
both  by  rectum  and  particularly  by  the  preparation 
of  ipecac  called  emetin  subcutaneously,  is  effective. 
Amoebic  dysentery  is  an  intestinal  infection  which 
gains  entrance  through  the  mouth  and  which  is  pre- 
vented in  the  same  way  that  typhoid  and  cholera 
are  prevented. 

Dysentery  is  frequently  used  as  a  clinical  symptom 
to  designate  many  conditions  with  severe  diarrhea. 
These  conditions  may  be  due  to  a  variety  of  causes, 
some  of  which  are  bacterial.  The  so-called  infectious 
diarrhea  and  the  cholera  morbus  of  children  are  often 
bacterial  infections.  The  bacteria  gain  an  entrance 
through  the  mouth  from  food,  drink,  and  contaminated 
hands.  Flies  may  be  a  factor.  The  prevention  is 
the  same  as  that  of  the  other  diseases  transmitted  by 
ingestion. 


DISEASES  TRANSMITTED  BY  INGESTION  193 

In  the  Tropics,  particularly,  we  find  a  larger  number 
of  pathological  intestinal  conditions.  Various  micro- 
organisms, some  vegetable,  perhaps  more  animal,  are 
the  causative  factors,  all  of  which  gain  entrance  with 
the  food  and  water. 

Food  and  drink  may  be  the  carriers  of  various  small 
animal  parasites  or  of  their  eggs.  We  have  already 
discussed  the  tapeworms  and  the  trichinae,  which  occa- 
sionally infect  meat  and  fish,  and  the  necessity  of 
thorough  cooking  to  destroy  these  parasites.  But,  in 
addition,  other  animal  parasites  or  their  eggs  may 
accidentally  pollute  food  and  drink  and  give  us  a  wide 
variety  of  diseases.  Such  conditions,  however,  are  not 
common  in  the  United  States.  Among  such  infecting 
agents  are  the  flukes  (the  bilharzia  hematobia  of  South 
Africa,  Egypt,  and  Asia),  and  the  hydatid  worms  which 
cause  echinococcus  disease.  While  these  diseases  are 
almost  unknown  to  us,  they  emphasize  the  necessity  of 
avoiding  contamination  of  food  and  drink.  The  hook- 
worms (uncinaria)  which  usually  enter  the  body 
through  the  skin,  are  apparently  occasionally  ingested. 

There  are,  of  course,  still  other  diseases  which  are 
transmitted  in  the  same  way  as  typhoid  fever,  cholera, 
and  dysentery.  Tuberculosis  is  one  of  these.  Scarlet 
fever,  as  a  rule,  is  carried  by  the  so-called  droplet 
method,  but  it  may  be  caused  by  the  contamination  of 
some  food  supply,  especially  milk.  A  striking  example 
of  the  transmission  of  disease  is  the  so-called  septic 
sore  throat  which  is  transmitted  by  milk.  Septic 
sore  throat,  scarlet  fever,  diphtheria,  and  tuberculosis, 
are  sometimes  transmitted  in  the  food  supply,  but  not 
often  in  the  water  supply,  —  although  they  may  be. 
The  reason  that  milk  is  such  a  frequent  carrier  of  dis- 
ease is  that  it  is  an  excellent  culture  medium  for 
bacteria  and  that  bacteria  multiply  rapidly  in  it. 
Milk  may  also  carry  certain  diseases  of  the  animal 


194  HEALTH  AND  DISEASE 

which  gives  the  milk.  From  the  cow  tubercle  bacilli 
and  streptococci  may  pass  into  the  milk  and  respec- 
tively cause  tuberculosis  and  septic  sore  throat.  Like- 
wise, goats  may  pass  the  infecting  agents  of  Malta 
fever  (a  fever  occurring  along  the  Mediterranean) 
in  the  milk.  The  prevention  of  disease  from  such  milk 
is  obvious :  (1)  sound  animals,  and  (2)  pasteurization 
or  boiled  milk  in  case  of  doubt.  But  these  diseases, 
except  Malta  fever,  are  not  usually  transferred  by 
ingestion  and  so  they  will  be  discussed  under  their 
usual  method  of  transmission. 


CHAPTER  XII 

THE  AIR-BORNE  DISEASES 

UNDER  air-borne  diseases,  by  a  somewhat  loose  usage, 
we  may  include  a  long  list  of  diseases  in  which  the 
channels  of  entrance  and  exit  are  the  air  passages. 
The  medium  of  transfer  is  the  air,  in  which  the  bacteria, 
usually  breathed,  coughed,  or  sneezed  out  in  droplets, 
pass  from  person  to  person.  This  group  of  infections 
includes  some  of  the  most  important  diseases  which 
affect  mankind.  This  group  would  still  be  of  the  ut- 
most importance  if  it  included  no  diseases  in  addition 
to  tuberculosis  and  pneumonia,  which  have  been 
running  a  close  race  to  see  which  could  kill  the  more 
people  in  a  year.  Just  at  present  pneumonia  is  in  the 
lead,  but  pneumonia  cannot  compare  with  tubercu- 
losis as  a  cause  of  poverty  and  social  ills.  Smallpox, 
diphtheria,  and  the  so-called  children's  diseases  — 
measles,  scarlet  fever,  whooping  cough,  and  chicken- 
pox  —  are  all  transferred  by  the  droplet  method.  In 
some  of  these  diseases  we  do  not  know  the  actual 
germ,  but  it  has  been  shown  that  they  are  carried  from 
person  to  person  in  the  air. 

In  this  group  of  diseases  the  disease  itself  may  or 
may  not  be  confined  to  the  respiratory  tract  which 
merely  serves  as  a  channel  of  exit  and  entrance.  The 
micro-organisms  of  such  diseases  are  usually  borne  in 
minute  particles  of  moisture.  These  droplets  are 
given  off  through  the  nose  and  throat,  and  another 
person  may  or  may  not  be  infected  by  them.  The 

195 


196  HEALTH  AND  DISEASE 

spread  of  the  infection  depends  upon  three  things : 
the  number  of  organisms,  the  virulence  of  the  organ- 
isms, and  the  resistance  of  the  individual. 

In  some  instances  the  vitality  of  the  causative  micro- 
organism is  so  slight  outside  the  human  body  that  the 
infection  must  be  passed  immediately  from  person  to 
person.  This  is  frequently  loosely  called  contact, 
since,  to  be  infected,  the  victim  must  come  within  a 
short  distance  of  the  infected  person.  This  is  the  case 
in  whooping  cough.  In  other  instances  the  micro- 
organisms are  hardy  and  live  for  some  time  outside 
the  body  and  close  association  may  not  be  necessary. 
This  seems  to  be  particularly  true  of  the  tubercle 
bacillus.  The  sputum  of  a  tuberculous  individual 
may,  under  favorable  conditions,  contain  the  living 
bacilli  for  days  and  even  weeks. 

Coughs  and  Colds 

Coughs  and  colds  are  transmitted  in  this  same  way, 
but  in  regard  to  the  micro-organisms  which  cause 
colds  there  is  a  complicated  bacteriological  tangle. 
Certain  epidemics  of  colds  are  apparently  caused  by 
the  pneumococcus ;  others  by  the  influenza  bacillus, 
and  still  others  by  various  organisms.  The  micro- 
organism of  the  common  cold  has  not  been  discovered, 
although  the  researches  of  Foster  suggest  that  he  has 
isolated  the  specific  bacterium.  Attempts  have  been 
made  to  use  a  vaccine  against  colds,  but  they  have 
been  of  little  success,  for  the  reason  that  the  im- 
munity conferred  by  the  disease  is  short  and,  further, 
because  we  do  not  yet  possess  sufficient  knowledge  of 
the  bacteriology  of  colds.  Colds  are  not  always 
transmitted  through  the  air.  Careless  people  may 
infect  others  by  contact,  such  as  by  using  a  common 
drinking  cup  or  common  towel,  which  may  thus  afford 


THE  AIR-BORNE  DISEASES  197 

the  infecting  droplets  an  opportunity  of  entrance  into 
the  nose  and  throat. 

Colds  and  the  allied  conditions  tend  to  be  self- 
limited.  The  infection  is  aggravated  and  prolonged 
by  abnormal  conditions  of  the  nose  and  throat  and  by 
poor  physical  conditions,  and  so  the  remedial  measures 
are  directed  largely  against  these  two  contributing 
factors.  The  cure  of  a  cold  is  primarily  brought  about 
by  the  body  itself,  for  there  is  no  specific  cure. 

Colds  are  extremely  infectious  as  is  illustrated  by 
the  fact  that  a  cold  frequently  "  runs  through  "  an 
entire  family.  We  have  already  mentioned  the  tre- 
mendous economic  loss  and  some  of  the  sequelae  of 
colds.  Colds,  like  all  the  air-borne  diseases,  are  diffi- 
cult of  prevention  in  contrast  to  the  relatively  easy 
prevention  of  the  diseases  caused  by  ingestion.  This 
difficulty  is  well  illustrated  by  the  seasonal  occurrences 
of  colds.  They  are  largely  winter  diseases,  merely  be- 
cause in  winter  we  have  favorable  conditions  of  spread. 
These  conditions  are  the  close  proximity  of  persons, 
the  closed  rooms  with  the  inevitable  concentration  of 
the  infective  droplets,  and  the  usual  lessened  physical 
efficiency  of  winter. 

The  real  danger  in  this  so-called  droplet  method  of 
infection  is  the  actual  proximity  of  the  infected  person. 
The  prevention  of  colds  and  also  of  the  other  air-borne 
diseases  is  almost  entirely  an  individual  problem. 
It  is  incumbent  on  the  individual  to  avoid  and  correct 
abnormality  and  irritation  of  the  upper  air  passages 
and  to  keep  his  physical  condition  as  nearly  perfect  as 
possible.  Then,  an  intelligent  appreciation  of  the 
method  of  spread  of  the  air-borne  diseases  will  enable 
him  to  .avoid  wherever  possible  the  close  proximity  of 
infected  persons  and  to  prevent  the  concentration  of 
infective  droplets  in  a  closed  place.  Promiscuous 
coughing,  sneezing,  and  spitting  into  any  but  proper 


198  HEALTH  AND  DISEASE 

receptacles  are  obviously  dangerous  and  should  be 
prohibited.  The  use  of  common  utensils  is  also  dan- 
gerous. At  best,  infection  is  always  easy,  but  the 
individual  can  do  much  by  developing  proper  habits 
to  prevent  these  diseases.  Since  every  case  of  infec- 
tion is  a  starting  point  for  other  cases,  the  continuous 
prevention  of  a  few  cases  will  mean,  in  the  end,  a 
marked  reduction  or  eradication  of  these  diseases. 

Influenza 

True  influenza  is  a  distinct  disease  and  is  not  an 
ordinary  cold  or  "  grippe."  The  disease  is  due  to  a 
specific  bacillus  which  can  be  isolated  readily  and 
which,  of  course,  is  entirely  distinct  from  the  micro- 
organism which  causes  the  cold  or  "  grippe."  In- 
fluenza makes  its  appearance  periodically  and  sweeps 
over  the  entire  world  in  great  pandemics.  It  usually 
starts  in  Russia  and  works  westward  through  the  con- 
tinent and  thence  to  the  United  States.  The  last  great 
epidemic  was  in  1894.  Since  that  time  influenza  has 
been  with  us  constantly.  The  transfer  and  prevention 
are  essentially  the  same  as  for  colds  and  the  latter 
depends  on  the  general  practice  of  good  personal  habits. 

Diphtheria 

The  infection  of  diphtheria  is  caused  by  a  bacillus, 
which  is  known,  after  its  discoverers,  as  the  Klebs- 
LoefHer  bacillus.  Diphtheria  is  also  known  as  mem- 
branous croup.  As  a  matter  of  fact  some  cases  of  sore 
throat  are,  in  reality,  unrecognized  cases  of  diphtheria. 

The  disease  has  been  recognized  for  many  cen- 
turies, but  it  was  not  until  1821  that  the  clinical  ob- 
servations of  Brentonneau,  of  Tours,  established  its 
separate  identity.  Diphtheria  occurs  in  nearly  all 


THE  AIR-BORNE  DISEASES  199 

parts  of  the  world,  but  it  is  most  prevalent  in  the 
Temperate  zone.  While  it  occurs  in  epidemics  and  in 
sporadic  cases  and  is  endemic  in  nearly  every  large 
city,  it  is  more  common  in  the  country  districts. 
Diphtheria  occurs  most  frequently  between  the  ages 
of  two  and  eight.  One  attack  does  not  protect  and 
may  be  followed  by  several  attacks.  It  is  not  un- 
common for  people  who  take  care  of  diphtheria  pa- 
tients to  come  down  with  the  disease,  but  a  goodly 
proportion  of  people  are  naturally  immune  and  do  not 
contract  it  under  any  conditions  of  exposure. 

The  incubation  period  of  diphtheria,  that  is  the  time 
required  for  the  development  of  the  disease  after  the 
infection  is  received,  is  short,  only  one  to  five  days. 
While  the  infection  is  largely  conveyed  by  the  air,  a 
number  of  epidemics  have  been  traced  to  infected  food 
and  drink,  notably  milk.  The  writer  has  recently 
traced  an  epidemic  to  infected  salad  dressing.  Under 
favorable  conditions  diphtheria  bacilli  remain  alive 
outside  the  body  for  weeks.  As  in  a  number  of  other 
diseases,  there  are  carriers  of  diphtheria.  Apparently 
healthy  persons  without  sore  throats  and  others  after 
recovery  from  diphtheria  harbor  the  micro-organisms 
in  their  throats  for  varying  lengths  of  time.  These 
people  often  spread  the  disease. 

The  diagnosis  of  diphtheria  can  usually  be  made 
by  an  examination  of  the  throat  and  the  symptoms. 
The  only  positive  method,  however,  is  the  examination 
after  twenty-four  hours  of  the  organisms  which  have 
grown  on  suitable  media  from  the  secretions  of  the 
nose  and  throat. 

The  average  mortality  from  diphtheria  has  been 
reduced  one-fourth  or  more  since  the  introduction  of 
antitoxin  in  1894.  The  duration  of  the  individual 
attack  has  been  shortened  and  its  severity  lessened. 

Moreover,  through  the  use  of  prophylactic  injec- 


200  HEALTH  AND  DISEASE 

tions  of  antitoxin,  the  spread  of  the  disease  has  been 
checked  and  numerous  epidemics  brought  to  an  end. 
In  one  hospital,  February  to  June,  1894,  448  children 
were  admitted  suffering  from  this  disease  and  109,  or 
24.5  per  cent,  died.  Serum  was  used.  In  another  hos- 
pital over  a  corresponding  period  of  time,  out  of  520 
cases  316  or  sixty  per  cent  died.  Here  no  serum  was 
used.  With  the  improvement  in  antitoxin,  an  analysis 
of  80,000  cases  that  received  it  at  any  time  showed  a 
mortality  of  fifteen  per  cent.  If  antitoxin  is  used  in 
the  first  two  days  of  the  disease,  the  mortality  is  under 
eight  per  cent. 

In  1883,  the  year  before  the  discovery  of  the  diph- 
theria bacillus,  which  enabled  a  positive  diagnosis  to 
be  made,  97  out  of  every  100,000  of  the  population  of 
the  eighteen  largest  cities  of  Europe  and  America  died 
of  diphtheria.  Undoubtedly  there  were  many  more 
deaths  due  to  diphtheria  but  attributed  to  other 
causes  since  an  exact  diagnosis  could  not  be  made. 
In  twenty  years  the  mortality  had  been  reduced  some- 
what, due  largely  to  the  ability  to  make  an  early  diag- 
nosis and  to  quarantine.  In  1900  in  the  United  States 
registration  area  the  mortality  from  diphtheria  was 
43  per  100,000.  The  decline  since  1900  is  relatively 
greater  than  that  shown  by  any  other  important  cause 
of  death.  The  decline  in  the  mortality  is  much  greater 
in  diphtheria  than  in  any  other  of  the  air-borne  infec- 
tions and  must  be  attributed  to  the  increasing  use  of 
antitoxin.  It  must  be  remembered,  furthermore,  that 
even  to-day  a  large  proportion  of  the  fatal  cases  of 
diphtheria  either  do  not  receive  antitoxin  or  only  when 
moribund.  The  antitoxin  reduces  the  mortality  from 
diphtheria  in  two  ways.  Given  to  the  patient  it  acts 
as  a  cure  for  the  disease.  Given  to  exposed  persons  it 
protects  them  from  contracting  the  disease.  To  be 
sure  the  protection  afforded  is  short  —  only  two  to 


THE  AIR-BORNE  DISEASES  201 

six  weeks  —  but  that  is  sufficient  to  protect  during  the 
course  of  an  ordinary  epidemic. . 

Diphtheria  antitoxin  is  a  substance,  or  substances, 
in  blood  serum,  usually  of  a  horse,  which  neutralizes 
the  poison  or  toxin  given  off  by  the  bacillus  of  the 
disease.  In  the  case  of  the  diphtheria  bacillus,  the 
toxin  is  a  poison  which  is  not  in  the  bacteria  itself, 
but  which  is  diffused  throughout  the  system  of  the 
individual.  Recovery  depends  on  the  presence  of 
antitoxin  which  may  be  produced  naturally  by  the 
body  or  supplied  artificially.  The  blood  from  a  horse, 
which  has  had  diphtheria  toxins  injected  repeatedly 
at  suitable  intervals,  neutralizes  the  poisons  of  diph- 
theria in  enormous  amounts,  but  not  at  all  the  poisons 
or  toxins  of  other  bacteria.  The  fluid  part  of  the  blood 
of  such  a  horse,  after  coagulation,  which  is  known  as 
serum,  when  given  to  the  patient  suffering  from  diph- 
theria, will  neutralize  all  the  poison  of  diphtheria  in  the 
body  of  the  patient.  The  effect  is  due  to  the  anti- 
toxin in  the  serum  and  not  to  the  serum  itself,  although 
serum  and  antitoxin  are  sometimes  incorrectly  as- 
sumed to  be  synonymous.  Diphtheria  antitoxin  was 
the  first  and  it  is  still  the  most  effective  antitoxin 
we  have.  The  effects  of  the  diphtheria  antitoxin 
disappear  rather  rapidly  and  only  protect  for  a  short 
time.  In  other  words,  the  antitoxin  will  not  protect 
for  any  longer  time  than  an  attack  of  the  disease. 

It  should  be  rather  easy  to  stamp  out  diphtheria, 
because  there  is  available  an  early  method  of  diagnosis 
by  means  of  cultures  taken  from  the  nose  and  throat, 
the  cure  of  the  disease  itself  by  antitoxin,  and  the 
prevention  of  transmission  of  the  disease  by  making 
all  exposed  persons  immune  through  the  use  of  anti- 
toxin. Furthermore,  it  is  possible  to  tell  by  bacteri- 
ological examination  at  what  time  the  patient  ceases 
to  harbor  the  micro-organisms  and  by  the  same  simple 


202  HEALTH  AND  DISEASE 

method  detect  carriers.  This  examination  is  so  impor- 
tant that  it  is  performed  free  of  charge  by  all  state 
boards  of  health  and  by  the  boards  of  health  of  most 
cities. 

There  has  been  perfected  recently  a  test  which 
shows  whether  a  person  is  certainly  immune  to  diph- 
theria (Schick's  test  for  antitoxic  immunity).  This 
test  enables  us  to  determine  a  percentage  of  those 
persons  who  are  actually  immune.  While  the  reduc- 
tion in  the  diphtheria  mortality  has  been  marked,  yet 
it  is  the  failure  to  utilize  these  additional  weapons 
which  we  have  in  diphtheria  as  in  no  other  disease, 
which  explains  why  this  disease  has  not  been  practi- 
cally eradicated.  Unlike  most  air-borne  infections, 
early  diagnosis  by  the  bacteriological  examination  is 
easy  and  accurate  and  thus  prevention  by  quarantine 
and  isolation  not  only  of  those  actually  sick  but  of 
all  carriers  is  unusually  effective.  In  handling  a  case 
of  the  disease  great  care  should  be  used  in  the  disposal 
of  material  contaminated  by  the  secretions,  for,  under 
favorable  conditions,  the  diphtheria  bacillus  may  be 
long  lived  outside  of  the  body.  Fortunately,  the 
bacillus  is  easily  killed  by  the  ordinary  methods  of 
disinfection. 

The  claim  is  sometimes  made  that  antitoxin  works 
harm.  It  is  argued  that  lockjaw  and  various  loath- 
some diseases  are  introduced  into  the  body  with  the 
antitoxin.  Since  the  horse  is  not  susceptible  to  and 
cannot  carry  most  human  diseases,  including  syphilis, 
the  introduction  of  disease  must  be  due  to  gross  care- 
lessness in  the  handling  of  the  serum.  Obviously 
every  precaution  should  be  taken  in  securing  the  serum. 
All  sera  are  now  licensed  by  the  U.  S.  Public  Health 
Service,  and  in  Massachusetts  and  other  states,  the 
state  itself  produces  the  antitoxin  and  guarantees  its 
purity. 


THE  AIR-BORNE  DISEASES  203 

Some  eight  to  ten  days  after  the  injection  of  anti- 
toxin certain  patients  have  rashes  and,  rarely,  joint 
pains.  This  condition,  called  serum  sickness,  is  tran- 
sitory and  is  due  to  the  injection  of  a  foreign  serum. 
Thus  it  is  a  mild  manifestation  of  anaphylaxis.  In 
very  rare  cases  (less  than  a  hundred  have  been  collected) 
severe  anaphylaxis  and  death  may  develop  imme- 
diately after  the  injection  of  the  serum.  In  most 
cases  the  individual  had  previously  shown  marked 
susceptibility  to  horse  protein,  usually  in  the  form  of 
asthma  when  near  horses.  Individuals  with  a  history 
of  horse  asthma  should  receive  antitoxin  produced  in 
some  other  animal  than  the  horse. 

Children's  Diseases 

The  term  **  children's  diseases  "  means  that  such 
diseases  are  so  contagious  that  an  individual  will 
catch  them  as  soon  as  he  goes  out  and  mingles  with 
his  fellow  beings.  All  of  the  children's  diseases  are 
spread  by  the  droplet  method  of  infection.  We 
include  in  this  category,  as  a  rule,  measles,  scarlet 
fever,  chicken  pox,  mumps,  and  whooping  cough. 

Measles.  Measles  has  been  known  for  so  long 
and  through  so  many  generations  that  the  race  has 
acquired  a  certain  immunity  to  the  disease.  A  mod- 
erate protection  is  conferred  by  one  attack  of  measles, 
and  second  attacks  are  not  common.  The  incubation 
period  of  measles  (the  time  from  exposure  to  the  devel- 
opment of  the  disease)  is  nine  to  eleven  days. 

The  exact  cause  of  measles  is  unknown,  but  we  do 
know  that  it  is  a  disease  peculiar  to  man,  although  it 
can  be  given  to  animals.  In  common  with  a  number 
of  other  diseases,  measles  starts  as  an  ordinary  cold, 
but  the  rash,  which  is  the  only  way  in  which  we  can 
diagnose  the  disease,  may  not  appear  until  the  person 


204  HEALTH  AND  DISEASE 

has  been  ill  for  three  or  four  days.  Experimentation 
has  shown  that  the  poison  has  been  in  the  blood  and 
nasal  secretions  before  that  time.  This  is  an  important 
point,  because  it  means  that  people,  usually  children, 
wander  about  thinking  that  they  have  an  ordinary 
cold.  Then  they  come  down  with  measles  after  spread- 
ing the  disease  far  and  wide.  The  prevention  of  measles 
is  difficult  for  this  reason.  So  far  as  we  know,  measles 
is  spread  almost  entirely  by  the  droplet  method  from 
secretions  of  the  nose  and  throat,  just  as  are  colds,  but 
measles  are,  if  anything,  the  more  "  catching." 

There  is  no  evidence  that  measles  is  spread  from  the 
skin,  and  the  scaling  of  measles,  often  regarded  as 
highly  dangerous,  probably  never  carries  the  disease. 
Possibly  there  are  carriers  of  measles  or  the  disease 
may  be  transferred  by  a  third  person.  However, 
this  point  is  not  established  by  bacteriological  exami- 
nation, since  we  do  not  know  the  organism.  All  our 
evidence  points  to  the  immediate  transfer  from  person 
to  person,  particularly  in  the  pre-eruptive  stage  before 
the  diagnosis  is  possible  and  also  by  unrecognized 
cases. 

Measles  is  notoriously  communicable,  but  close 
proximity  to  patients  or  discharges  from  the  nose  and 
throat  seems  to  be  the  determining  factor  of  infection. 
For  example,  measles  can  be  cared  for  in  the  same  build- 
ing or  in  the  same  ward  with  other  patients  and  the 
disease  will  not  spread.  But  this  requires  the  most 
scrupulous  precautions  of  asepsis.  The  disease  is 
not  air-borne  in  the  sense  that  a  current  of  air  from  the 
room  of  the  patient  with  measles  carries  the  infection 
into  another  room.  The  method  of  infection  seems  to 
be  the  transfer  of  the  moist  secretions  of  nose  and  throat 
by  the  droplets  of  coughing  or  sneezing  in  the  air  or 
by  contaminated  hands  and  the  like.  Disinfectants 
and  fumigation  after  the  convalescence  of  the  patient 


THE  AIR-BORNE  DISEASES  205 

are  of  little  importance.  The  strictest  precautions 
should  be  observed  in  the  possible  transfer  during  the 
course  of  the  disease.  In  epidemics  rigid  quarantine 
is  necessary  not  only  for  those  with  the  disease,  but 
also  for  those  exposed  until  the  incubation  period  of 
ten  days  is  past. 

Measles  is  usually  regarded  as  an  innocuous  disease, 
but  measles  and  its  sequelae,  especially  pneumonia, 
cause  many  deaths.  As  a  rule  it  leads  scarlet  fever  in 
the  mortality  tables,  but  in  1914  measles  was  exceeded 
by  whooping  cough.  German  measles  is  merely  a 
mild  disease  very  similar  to  measles. 

Scarlet  Fever.  Scarlet  fever  is  one  of  the  most 
important  of  the  children's  diseases  from  every  stand- 
point. We  do  not  know  the  exact  cause  of  the  disease, 
although  Dr.  Mallory,  of  Boston,  has  made  a  preliminary 
report  on  a  bacillus  which  may  be  the  infecting  agent. 
Scarlet  fever  is  usually  transmitted  through  the  air 
by  the  droplet  method,  but  there  have  been  several 
large  epidemics  in  which  the  disease  was  carried  by 
milk.  Scarlet  fever  is  not  so  communicable  as  measles. 
It  may  be  carried  from  one  person  to  another  by  an 
indirect  method  either  by  persons  or  by  inanimate 
objects. 

Scarlet  fever  is  contracted  through  the  nose  and 
throat.  The  onset  of  the  disease  is  usually  from 
two  to  five  days  after  exposure,  and  the  first  symptom 
is  usually  a  sore  throat  which  antedates  the  eruption 
by  one  or  two  days.  Incurable  nephritis  (kidney 
disease)  is  frequently  traced  to  an  earlier  attack  of 
scarlet  fever.  Valvular  disease  of  the  heart  is  an- 
other sequela.  In  some  epidemics  of  scarlet  fever  the 
immediate  mortality  reaches  thirty  per  cent,  but  this 
is  unusual.  The  danger  in  scarlet  fever  is  on  account 
of  the  remote  complications.  Measles  is  the  imme- 
diate cause  of  more  deaths  than  scarlet  fever,  due  not 


206  HEALTH  AND  DISEASE 

to  the  measles  itself,  in  which  the  mortality  is  low,  but 
to  the  immediate  complications,  especially  of  the 
lungs.  Yet  scarlet  fever  is  a  more  serious  disease  than 
measles  on  account  of  the  frequency  and  severity  of  the 
remote  complications  like  nephritis  and  heart  disease. 

One  attack  of  scarlet  fever  seems  to  protect  against 
another  attack,  but  cases  of  individuals  having  it 
twice  are  by  no  means  rare.  Since  we  do  not  know 
the  organism  of  the  disease,  the  recognition  of  the 
length  of  infectivity  of  a  patient,  of  carriers,  and  of 
mild  cases  is  impossible.  Like  measles,  the  disease  is 
usually  only  to  be  diagnosticated  by  a  rash  which  is 
by  no  means  the  initial  symptom.  Prevention  is 
extremely  difficult.  All  the  evidence  points  to  the 
transmission  from  the  discharges  of  the  nose  and 
throat  and  the  disease  probably  gains  entrance  in  the 
same  way.  For  years  the  period  of  scaling,  which  occurs 
late  in  the  disease,  was  regarded  as  the  main  infective 
period  and  the  scales  were  considered  to  carry  the 
disease.  There  are  unquestionably  scarlet  fever  pa- 
tients who  spread  the  disease  after  recovery,  but, 
almost  invariably  in  these  cases,  the  early  inflammatory 
condition  of  the  nose  and  throat  has  not  entirely  sub- 
sided. For  the  release  of  patients  from  quarantine 
a  normal  nose  and  throat  seem  to  be  a  fairer  criterion, 
both  to  the  patient  and  the  public,  than  the  absence  of 
scaling. 

The  writer  is  familiar  with  a  case  of  scarlet  fever  in 
which,  before  the  eruption  appeared,  a  surgeon  per- 
formed tracheotomy  to  prevent  suffocation.  The 
next  day  the  child  showed  a  typical  rash  of  scarlet 
fever,  and  later  the  surgeon  developed  the  disease. 
As  the  surgeon  operated  with  gloves  and  in  a  surgical 
gown,  the  presumption  is  that  the  infection  was  by 
droplets  from  the  throat  before  the  eruption  occurred. 
Scaling  was  much  delayed  in  the  case  of  the  surgeon 


THE  AIR-BORNE  DISEASES  207 

and  it  was  afterwards  learned  that  he  mingled  with 
people  to  such  an  extent  that  if  the  scales  carried  the 
disease  widespread  infection  should  have  occurred. 
In  point  of  fact  no  case  developed.  Such  incidents 
could  be  multiplied. 

During  the  course  of  scarlet  fever  not  only  should 
active  and  strict  quarantine  be  employed  for  actual 
cases  but  also  isolation  in  an  epidemic  for  all  sore 
throats  and  exposed  persons.  As  in  the  case  of  measles, 
quarantine  need  not  demand  separate  buildings  as 
the  air  itself  is  not  dangerous  as  it  passes  over  and  from 
the  patient.  The  danger  lies  in  particles  of  infective 
material  from  the  nasal  secretions,  usually  carried  in 
small  droplets  directly  to  the  nose  and  throat  of  other 
people,  but  these  particles  can  be  transferred  in  many 
ways  during  close  proximity.  The  proximity  of 
handling,  for  example,  is  dangerous.  So  all  secretions 
of  the  nose  and  throat  should  be  disposed  of  carefully. 
So-called  terminal  disinfection  after  the  disease  may 
be  used,  but  it  is  of  doubtful  value. 

Chicken  Pox.  Chicken  pox  is  a  mild  disease  which 
results  from  some  unknown  cause.  One  attack  seems 
to  protect  against  another  attack.  The  incubation 
period  is  probably  about  twelve  days.  From  the 
point  of  view  of  health  chicken  pox  is  not  a  dangerous 
disease.  The  onset  is  usually  as  a  cold,  so  the  methods 
of  transmission  and  prevention  are  presumably  the 
same  as  those  for  colds,  measles,  and  scarlet  fever. 
Mild  unrecognized  cases  frequently  spread  the  disease. 

Mumps.  Mumps  is  another  of  the  so-called  chil- 
dren's diseases.  Mumps  is  characterized  by  a  swell- 
ing of  the  parotid  and  sometimes  of  all  of  the  salivary 
glands.  Here  again  we  do  not  know  the  cause  of  the 
disease,  but  it  is  presumed  that  the  infecting  agent  is 
a  micro-organism.  The  incubation  period  is  about 
three  weeks.  One  attack  gives  only  moderate  protec- 


208  HEALTH  AND  DISEASE 

tion  against  a  subsequent  attack.  With  the  exception 
of  the  fact  that  mumps  causes  no  rash,  it  is  similar 
to  measles,  scarlet  fever,  and  chicken  pox.  The 
methods  of  transmission  and  prevention  are  the  same. 
Here,  again,  the  person  may  not  know  that  he  has  the 
disease  and  so  spread  the  infection.  Any  fatality  from 
mumps  is  an  excessively  rare  occurrence.  A  not  un- 
common complication  of  mumps  is  the  involvement  of 
the  testicles  in  the  male  and  the  ovary  in  the  female. 
If  both  testicles  of  the  male  are  involved,  sterility  may 
result. 

Whooping  Cough.  Whooping  cough  belongs  in  the 
group  of  children's  diseases.  We  know  that  the 
causative  agent  is  a  small  bacillus  which  has  been  iso- 
lated. Whooping  cough  is  an  important  cause  of 
disease  and  death  among  children,  and  in  weak,  puny 
children  it  is  apt  to  cause  serious  complications.  While 
the  disease  in  itself  may  not  be  especially  serious, 
deaths  due  to  it  directly  or  indirectly  are  rather  com- 
mon. In  1914  whooping  cough  was  given  as  the  cause 
of  more  deaths  than  measles  or  scarlet  fever.  The 
mortality  figures  vary  widely  from  year  to  year  and 
there  seems  to  be  no  general  tendency  to  increase  or 
decrease.  One  attack  of  whooping  cough  more  or  less 
prevents  other  attacks.  Attempts  have  been  made  to 
secure  a  vaccine  or  antitoxin,  but  the  difficulty  lies  in 
the  early  recognition  of  the  disease,  for  it  may  go  on 
for  a  week  or  so  before  it  is  recognized.  Even  after 
recognition  the  disease,  and  sometimes  the  infectivity, 
may  persist  for  weeks. 

Whooping  cough  is  usually  only  communicable  by 
immediate  association.  The  infection  is  presumably 
carried  from  the  secretions  of  the  nose  and  throat,  but 
it  seems  to  be  short  lived  outside  the  body  and  only 
transferable  for  short  distances.  Some  of  the  domes- 
tic animals  seem  to  suffer  from  whooping  cough  and 


THE  AIR-BORNE  DISEASES  209 

may  transfer  the  disease.  The  prevention  is  by  quar- 
antine of  the  victim.  Fumigation  is  unnecessary,  but 
the  proper  disposal  of  the  discharges  from  the  nose  and 
throat  is  important. 

General  Considerations  in  Diphtheria  and  the 
Children's  Diseases.  All  these  diseases  have  certain 
characteristics  in  common.  All  apparently  originate 
in  the  nose  and  throat,  and  most  of  them  start  like  a 
cold  or  sore  throat  and  may  be  difficult  of  recognition 
in  the  early  stages.  Ever  since  we  have  had  statistics 
of  disease,  we  have  had  little  diminution  in  the  chil- 
dren's diseases,  with  the  exception  of  diphtheria.  And 
until  we  know  the  precise  causes  of  the  infections  we 
cannot  know  the  precise  methods  to  combat  the  dis- 
eases. We  have  frankly  to  admit  that  in  combat- 
ing this  group  of  diseases  we  have  not  been  very 
successful.  Isolation  has  not  been  successful.  But  we 
can  point  out  that  smallpox,  the  worst  of  these  air- 
borne diseases,  has  been  prevented  by  vaccination. 

With  the  exception  of  diphtheria,  the  chief  depend- 
ence for  the  prevention  of  the  spread  of  this  group  of 
diseases  is  by  quarantine.  And  yet,  due  to  the  diffi- 
culties of  diagnosis,  the  cases  are  often  at  large  when 
perhaps  most  dangerous.  The  general  method  of 
boards  of  health  in  combating  these  diseases  is  to 
placard  the  house  of  the  victim,  which  makes  a  sort 
of  quarantine  or  isolation.  In  measles  the  attendants 
are  allowed  to  go  about.  More  precautions  are  taken 
with  scarlet  fever.  These  methods  are,  of  course, 
important,  particularly  where  they  include  the  isola- 
tion of  suspects  and  exposed  persons,  but  they  are 
probably  of  greatest  moment  in  the  education  of  the 
people  to  a  knowledge  that  these  diseases  are  com- 
municable. 

The  efficiency  of  quarantine  can  be  tested  by  the 
examination  of  statistics.  While  quarantine  has 


210  HEALTH  AND  DISEASE 

doubtless  prevented  widespread  epidemics,  yet,  in 
the  main,  scarlet  fever,  whooping  cough,  measles, 
mumps,  and  chicken  pox  go  on  in  much  the  same 
amount  now  as  formerly.  But  not  so  with  diphtheria. 
During  the  same  period  —  since  1880  —  the  preva- 
lence of  diphtheria  has  been  reduced  enormously, 
but  in  this  case  we  have  the  use  of  other  means  than 
quarantine.  In  addition  we  may  recall  the  ineffec- 
tive control  of  smallpox  in  Germany  by  the  most  rigid 
quarantine.  Quarantine  should  not  be  given  up,  but 
it  seems  certain  that  such  diseases  as  are  spread  from 
the  secretions  of  the  nose  and  throat  and  are  presum- 
ably carried  in  the  form  of  droplets,  either  in  the  air 
or  in  discharges,  more  or  less  directly  to  other  people, 
can  be  eliminated  by  quarantine  very  slowly  if  at  all. 
Then,  too,  we  are  inclined  to  speak  of  quarantine 
as  a  fixed  thing.  Chapin,  of  Providence,  has  done 
much  to  upset  our  complacency  about  quarantine. 
What  is  effective  quarantine  for  one  disease  on  ac- 
count of  definite  characteristics  of  the  disease  and  the 
micro-organism,  may  not  be  at  all  effective  for  another. 
In  the  past  we  have  taken  elaborate  precautions  about 
the  transfer  of  air,  but  our  efforts  were  probably 
wasted.  Smaller  and  larger  particles  of  the  secretions 
of  the  nose  and  throat  are  the  dangerous  agents.  These 
particles  as  "  droplets  "  are  propelled  directly  by  cough- 
ing into  the  noses  and  throats  of  other  people.  In  addi- 
tion, these  particles,  especially  with  children,  can  be 
transferred  on  common  utensils,  common  toys,  and 
the  like.  Nasal  discharges  and  sputa  carry  the  in- 
fection and  preserve  the  life  of  the  infecting  bacteria. 
But  these  infections  are  probably  not  air-borne  in  the 
sense  that  ordinary  air  conveys  the  infection  to  direct 
points.  They  are  air-borne  only  as  the  droplets  stay 
in  the  air.  The  term  "contact",  meaning  proximity, 
is  being  applied  more  and  more  to  this  type  of  case. 


THE  AIR-BORNE  DISEASES  211 

The  quarantine,  as  Chapin  has  shown,  should  be 
directed  towards  the  possible  transfer  of  the  nasal  or 
buccal  secretions.  This  includes  droplets  in  the  air, 
all  utensils,  and  the  like.  Further,  it  puts  precautions 
on  the  attendants.  Under  such  conditions  patients 
will  not  infect  others  in  the  same  room.  But,  on  ac- 
count of  human  frailty,  it  is  desirable  to  leave  a  wider 
gap  than  this  between  infected  patients  and  others, 
and  thus  the  desirability  of  continuing  quarantine. 
Until  we  have  additional  methods  of  prevention,  like 
vaccination  against  smallpox,  the  early  diagnosis,  and 
the  curative  and  prophylactic  antitoxic  serum  in 
diphtheria,  we  must  not  expect  too  much  of  quarantine. 

In  addition  to  quarantine,  much  or  more  can  be 
accomplished  in  the  way  of  prevention  by  sound  habits 
of  hygiene  on  the  part  of  the  individual.  Everyone 
should  be  extremely  careful  of  all  infections  of  the 
nose  and  throat.  Any  cold  is  a  possible  beginning  of 
any  one  of  these  special  infections,  and  this  is  an- 
other point  in  favor  of  a  reasonable  quarantine  of  the 
ordinary  cold.  In  general,  the  prevention  of  colds  and 
the  prevention  of  these  air-borne  and  contagious  dis- 
eases depends  upon  the  same  factor,  —  that  of  per- 
sonal hygiene.  Quarantine  will  always  be  necessary 
as  a  public  measure,  but  personal  hygiene  is  of  greater 
importance  and  should  be  so  regarded. 

Fumigation  may  or  may  not  be  of  value.  It  often 
gives  a  false  sense  of  security,  for  the  so-called  termi- 
nal fumigation  is  usually  carried  out  when,  by  the 
nature  of  things,  all  the  infecting  micro-organisms  have 
died  out.  Fumigation  may  be  perfectly  scientific, 
but,  when  we  do  not  know  the  cause  of  a  disease,  our 
fumigation  is  entirely  experimental  since  there  are  no 
means  of  checking  it  up.  Again  the  value  lies  in  the 
education  of  the  people  by  giving  them  a  concrete 
example  of  the  fact  that  the  disease  is  communicable. 


212  HEALTH  AND  DISEASE 

The  simplest  and  probably  the  most  effective  method 
of  fumigation  is  to  open  the  windows  and  let  in  the 
sunlight  and  fresh  air  and  not  allow  the  room  to  be 
occupied  for  a  few  days.  Thorough  mechanical  clean- 
ing with  soap  and  water  is  probably  of  value. 

Pneumonia 

Next  to  tuberculosis  in  importance  is  pneumonia. 
This  disease  causes  ten  per  cent  of  the  deaths  in  the 
United  States  each  year.  Formerly  tuberculosis  caused 
more  deaths  than  any  other  disease,  but  now  pneumonia 
ranks  with  the  "  Great  White  Plague."  The  death  rate 
from  pneumonia  fluctuates  widely  from  year  to  year 
and  one  is  inclined  to  suspect  the  accuracy  of  some  of 
the  records  of  deaths.  In  1900,  the  death  rate  from 
pneumonia  was  180.5  per  100,000,  and  in  1914,  127 
per  100,000.  The  figures  for  1914  were  the  lowest 
on  record,  but  with  the  general  reduction  of  deaths 
pneumonia  now  causes  a  greater  proportion  of  the 
mortality  than  formerly. 

Pneumonia  may  be  defined  as  an  inflammation  of 
the  lungs  and  the  usual  cause  of  the  disease  is  a  bac- 
terium belonging  to  the  coccus  group,  the  pneumococ- 
cus.  The  disease  attacks  people  of  all  ages,  in  all 
climates,  of  both  sexes,  at  all  times  of  the  year.  Old 
people  are  particularly  apt  to  be  carried  off  by  it,  as 
are  people  in  poor  condition,  especially  the  chronic 
alcoholics.  Pneumonia  occurs  in  early  life  and  is 
moderately  fatal,  but  in  old  age  it  is  so  fatal  that  it  is 
called  "  the  friend  of  the  aged."  In  middle  life  the 
mortality  varies.  Roughly  the  mortality  from  pneu- 
monia runs  about  twenty  per  cent. 

Pneumonia  is  another  of  the  self -limited  diseases. 
Recovery  from  pneumonia  is  extremely  rapid.  When 
the  disease  has  run  a  typical  course,  the  fever  often 


THE  AIR-BORNE  DISEASES  213 

drops  suddenly  to  normal,  a  so-called  crisis.  The 
immunity  afforded  by  an  attack  of  the  disease  lasts 
only  a  short  time,  and  people  who  have  had  it  once 
are  rather  more  liable  to  have  it  again.  It  is  evident, 
therefore,  that  if  the  disease  does  not  protect  against 
another  attack,  certainly  no  vaccine  will. 

Pneumonia  was  formerly  considered  one  of  those 
diseases  which  "happen",  and  there  was  considerable 
difficulty  in  recognizing  that  it  was  communicable. 
The  discovery  of  the  pneumococcus  as  the  cause  of  the 
disease  did  not  solve  the  problem.  Pneumococci  are 
found  in  many  normal  mouths  and  the  same  organ- 
isms are,  furthermore,  the  cause  of  colds,  tonsillitis, 
and  other  more  or  less  mild  disturbances.  While 
there  are  on  record  a  number  of  definite  epidemics  of 
pneumonia,  it  is  rare  for  doctors  and  nurses  to  contract 
the  disease  in  their  care  of  patients.  Then,  in  all 
general  hospitals  patients  suffering  with  pneumonia 
are,  as  a  rule,  cared  for  in  the  open  wards  and  cases 
among  the  other  sick  do  not  develop.  It  has  been 
suggested  that,  since  the  pneumococcus  is  a  rather 
easily  destroyed  organism,  ordinary  proximity  is  not 
dangerous.  Another  suggestion  is  that  the  factor  of 
resistance  may  be  the  determining  factor.  Yet  these 
suggestions  do  not  explain  adequately  the  enormous 
number  of  cases  of  pneumonia.  As  a  matter  of  fact 
we  have  no  complete  solution,  but  recent  researches, 
especially  at  the  Rockefeller  Hospital  in  New  York, 
have  given  us  much  additional  knowledge. 

We  now  know  that  pneumococci  may  look  alike  and 
grow  in  the  same  way,  but  still  be  different.  There 
are  at  least  four  groups  of  pneumococci.  The  pneu- 
mococcus present  in  the  normal  mouth  is  not  found 
in  the  form  of  pneumonia  with  a  high  mortality.  Still, 
not  only  the  patient,  but  those  who  care  for  the  patient, 
may  harbor  in  their  mouths  for  a  few  weeks  not  the 


214  HEALTH  AND  DISEASE 

ordinary  mouth  pneumococci,  but  the  pneumococci 
of  that  particular  pneumonia.  These  facts  were 
brought  out  in  the  attempts  to  secure  an  antitoxic 
serum  for  pneumonia.  It  was  found  that  the  serum 
of  a  horse,  highly  immunized  by  a  particular  pneu- 
mococcus,  contained  abundant  antitoxin,  but  that  this 
antitoxin  was  only  effective  against  the  toxin  of  that 
one  type  of  pneumococcus.  The  story  of  these  at- 
tempts to  find  a  serum  and  to  identify  the  various  types 
of  pneumococci  is  complicated  and  is  only  just  begun. 
It  is  sufficient  to  say  that,  in  spite  of  tremendous  ob- 
stacles, sera  have  been  developed,  which  are  promising  of 
future  achievements,  but  as  yet  no  such  brilliant  results 
as  are  seen  in  diphtheria  antitoxin  have  been  attained. 
In  the  meantime,  while  the  mechanism  of  infection 
in  pneumonia  is  not  entirely  clear,  pneumonia  should 
be  seriously  regarded  as  a  communicable  disease. 
Considerable  quarantine  should  be  enforced  and  strict 
precautions  should  be  taken  to  disinfect  all  the  excre- 
tions of  the  patient,  particularly  the  sputum.  We 
still  lack  the  necessary  knowledge  to  expect  success- 
fully to  combat  the  disease  or  to  prevent  it  to  any 
marked  degree. 

Tuberculosis 

Tuberculosis  is  an  infectious  disease  which  is  caused 
by  the  tubercle  bacillus.  The  disease  may  infect  any 
tissue  of  the  body  and  may  assume  a  wide  variety  of 
manifestations,  but  the  most  common  form  of  tuber- 
culosis is  that  of  the  lungs  —  consumption  or  phthisis. 
Five-sixths  of  all  the  cases  of  tuberculosis  and  of  the 
resulting  mortality  are  due  to  consumption.  But  it 
must  be  remembered  that  it  is  the  same  bacillus  which 
causes  all  forms  of  tuberculosis  and  that  the  non- 
pulmonary  forms  of  the  disease  may  be  fatal  and  a 
focus  of  infection. 


THE  AIR-BORNE  DISEASES  215 

Tuberculosis  of  the  lungs  or  consumption  was  well 
known  to  the  ancient  physicians.  Babylonian  tablets 
contain  accounts  of  the  disease,  and  Hippocrates 
(B.C.  460-376)  gave  a  lucid  description  of  it.  The 
latter  taught  that  "  the  consumption  came  from  the 
consumptive  ",  that  "  if  the  patient  is  treated  from 
the  beginning,  he  gets  well  ",  that  change  of  residence 
is  beneficial,  and  that  "  the  most  dangerous  disease 
and  the  one  which  proves  fatal  to  the  greatest  number 
is  consumption."  But  the  teachings  of  Hippocrates 
were  disregarded  until  the  middle  of  the  nineteenth 
century.  In  general,  consumption  was  regarded  as  a 
manifestation  of  Divine  displeasure.  It  was  usually 
considered  to  be  hereditary  and  the  best  medical 
authorities  taught  that  the  disease  was  not  catching. 
Consumption  seemed  to  be  incurable.  The  sporadic 
attempts  of  a  few  medical  men  to  furnish  their  con- 
sumptive patients  with  fresh  air  were  ridiculed  and 
the  patient  was  confined  to  a  heated,  closed  room  in 
which  remarkable  precautions  were  taken  to  keep  out 
sunlight  and  fresh  air. 

Knowledge  concerning  tuberculosis  accumulated 
slowly.  Bayle  (1803)  and  Laennec  (1819)  recognized 
the  unity  of  all  the  various  manifestations  of  tuber- 
culosis. In  1865,  through  experimentation,  the  disease 
was  transferred  to  animals.  In  1882  appeared  the 
epoch-making  work  of  Koch  announcing  the  discovery 
of  the  tubercle  bacillus  and  describing  its  habits. 
Since  that  time  we  have  been  able  intelligently  to 
study  tuberculosis  in  view  of  our  knowledge  of  the 
cause.  But  increased  knowledge  has  also  brought  an 
appreciation  of  the  difficulties  connected  with  the 
problem  of  tuberculosis. 

Frequency  of  Tuberculosis.  Autopsy  examinations 
have  shown  that  from  forty  to  ninety-five  per  cent  of 
persons  dying  from  any  cause  have  in  their  bodies 


216  HEALTH  AND  DISEASE 

some  focus,  usually  healed,  of  tuberculosis.  Further- 
more, the  incidence  of  tuberculosis  at  autopsy  is  nearly 
as  frequent  at  fifteen  years  as  in  adult  life.  In  this 
connection  it  is  necessary  to  draw  the  important 
distinction  between  infection  with  tuberculosis  and 
the  disease  of  tuberculosis.  The  scar  indicates  that 
the  person  has,  at  some  time,  been  infected  with  the 
tubercle  bacillus,  but  the  existence  of  the  scar  does  not 
mean  that  the  person  was  ever  sick  with  the  disease 
or  that  he  was  a  source  of  infection  to  others. 

But  these  facts  and  those  of  the  known  inci- 
dence of  the  disease  permit  the  following  deductions : 
(1)  Most  individuals  have  been  infected  with  tubercu- 
losis. (2)  This  infection  usually  occurs  in  childhood. 
(3)  The  infection  is  not  usually  followed  by  manifest 
tuberculous  disease.  (4)  Manifest  tuberculosis  or  tu- 
berculous disease  may  develop  many  years  after  the 
infection.  Thus  we  can  explain  the  incidence  of  a 
case  of  tuberculosis  apparently  remote  from  a  focus  of 
infection.  Of  still  greater  importance  is  the  applica- 
tion of  all  known  measures  to  prevent  not  only  infec- 
tion, but  the  change  from  infection  to  disease. 

Mortality  and  Morbidity  Statistics.  Up  to  about 
1880  tuberculosis  caused  from  one-fourth  to  one-fifth 
of  all  deaths.  With  the  discovery  of  the  tubercle 
bacillus  and  with  the  application  of  the  knowledge  that 
the  disease  is  communicable,  the  mortality  from  tuber- 
culosis has  slowly  decreased.  This  decrease  has  only 
been  noted,  however,  in  those  communities  in  which 
precautions  have  been  taken  to  prevent  the  spread  of 
the  contagion.  The  reasonable  isolation  of  the  con- 
sumptive has  everywhere  been  associated  with  a 
reduced  mortality.  Thus  statistics  of  tuberculosis 
mortality  vary  widely  for  different  localities.  In  the 
United  States  in  1915  tuberculosis  caused  slightly 
more  than  ten  per  cent  of  all  the  deaths,  a  total  of 


THE  AIR-BORNE  DISEASES  217 

98,194  in  the  registration  area  which  covers  two-thirds 
of  the  population.  Presumably  150,000  die  annually 
of  tuberculosis  in  the  United  States.  As  a  basis  for 
comparison,  it  may  be  remarked  that  in  the  Civil 
War  there  were  killed  or  died  from  wounds  205,000, 
averaging  about  50,000  each  year.  The  reduction 
from  twenty  to  twenty-five  per  cent  of  all  deaths  as  be- 
fore 1880  to  ten  per  cent  in  1915  is  to  be  attributed  to 
the  various  preventive  and  curative  measures  directly 
depending  on  Koch's  discovery  of  the  causative  agent. 

There  are  no  means  of  determining  how  many  peo- 
ple actually  suffer  from  tuberculosis.  From  various 
studies  it  seems  probable  that  for  each  death  there  are 
at  least  ten  sufferers  from  the  disease  in  any  given  year. 
Hence  there  are  probably  at  least  1,500,000  sufferers 
from  tuberculosis  in  the  United  States  at  the  present 
moment,  or  one  out  of  every  seventy  persons.  Out  of 
every  ten  births,  one  out  of  ten  will  die  of  tuberculosis 
sooner  or  later. 

Age  Incidence.  The  average  age  at  death  from 
tuberculosis  is  between  thirty  and  thirty-five.  Every 
third  death  during  the  working  period  of  life  is  caused 
by  tuberculosis.  The  average  period  of  total  disability 
before  death  is  over  one  year,  and  this  is  preceded  by 
a  period  of  partial  disability  likewise  averaging  over 
a  year.  Thus  tuberculosis  not  only  causes  death  dur- 
ing the  most  active  period  of  life,  but  the  long  dis- 
ability before  death  is  frequently  a  greater  financial 
burden  and  loss  than  the  actual  death.  Even  recovery 
from  tuberculosis  entails  a  large  financial  burden. 

Cost  of  Tuberculosis.  Statisticians  have  attempted 
to  determine  the  monetary  loss  caused  by  tuberculosis. 
But  it  is  obviously  impossible  to  translate  into  figures 
the  human  suffering,  the  misery  of  poverty,  and  many 
other  ills  which  tuberculosis  causes.  If  we  accept 
$8,000  as  the  value  of  the  adult  life,  including  the 


218  HEALTH  AND  DISEASE 

average  earning  capacity  for  the  future,  we  find  a 
yearly  loss  of  $1,200,000,000  in  the  United  States 
alone.  Such  computations  do  not  include  the  recovered 
cases  and  are  of  interest  only  as  indicating  in  a  small 
measure  the  tremendous  wastage  of  tuberculosis  even 
when  translated  into  dollars  and  cents. 

Transmission  of  Tuberculosis.  Tuberculosis  is  not 
hereditary.  A  few  cases  have  been  recorded  where 
the  mother  transmitted  tuberculosis  to  the  child  in 
the  uterus,  but  this  is  excessively  rare.  Formerly  we 
heard  much  of  an  inherited  predisposition  to  tuber- 
culosis, but  it  is  easily  possible  to  explain  the  well- 
known  frequency  of  the  occurrence  of  tuberculosis  in 
families  on  the  basis  of  increased  exposure.  It  may  be 
stated  definitely  that  there  is  no  positive  evidence  of 
an  inherited  predisposition  to  tuberculosis. 

The  tubercle  bacillus  may  gain  entrance  into  the 
body  in  the  following  ways  : 

1.  Through  the  air  passages  by  means  of  droplets 
directly  from  a  coughing  consumptive,  or  indirectly 
from  air-borne  particles  of  sputum  or  the  use  of  com- 
mon utensils. 

2.  Ingestion,    especially   in   milk   from   tuberculous 
cows,  or  food  which  has  been  contaminated  with  tuber- 
culous material  in  handling  or  by  flies. 

3.  Through   the    skin.     This    method    is    rare    and 
usually  gives  rise  to  a  local  tuberculosis  of  the  skin. 

By  far  the  most  common  method  of  transmission  is 
the  first.  The  tubercle  bacillus  is  rather  hardy  out- 
side the  human  body,  and  such  bacilli  have  been  found 
alive  in  dried  sputum  after  six  months.  They  may  live 
in  water  for  several  months.  Living  virulent  tubercle 
bacilli  apparently  live  almost  indefinitely  in  butter. 
Moisture  and  darkness  favor  the  prolongation  of  the 
life  of  the  tubercle  bacillus,  while  drying  to  desiccation 
of  the  contaminated  material  and  sunlight  favor  its 


THE  AIR-BORNE  DISEASES  219 

destruction.  This  bacillus  is  killed  by  ordinary  dis- 
infectants, but  penetration  of  the  material,  as  sputum, 
is  necessary. 

Any  material  which  contains  tubercle  bacilli  may 
spread  the  disease.  It  may  be  spread  by  all  the  dis- 
charges of  a  tuberculous  patient  and  by  the  discharges 
and  the  use  as  food  of  tuberculous  animals.  But  the 
general  sources  of  infection  are  two :  the  consumptive 
and  his  sputum,  and  the  tuberculous  cow  and  her 
milk.  The  sputum  of  the  consumptive  is  generally 
agreed  to  be  the  most  important  factor  in  the  spread  of 
the  tubercle  bacillus. 

Prevention  of  Tuberculosis.  The  first  consideration 
in  the  prevention  of  tuberculosis  is  the  prevention  of 
infection.  It  is  obviously  desirable  that  all  material 
containing  tubercle  bacilli  be  destroyed  before  it  can 
infect  others,  but  this  is  only  theoretically  possible. 
Presumably  there  are  a  million  and  a  half  persons  with 
active  tuberculosis  in  the  United  States,  and  institu- 
tional segregation  of  such  a  multitude  is  not  feasible. 
Furthermore,  many  consumptives  go  for  months  or 
years  spreading  the  disease  in  complete  ignorance  of 
the  fact  that  they  have  tuberculosis  or  that  they  are  a 
possible  menace  to  all  with  whom  they  come  in  con- 
tact. Long  experience,  especially  in  tuberculosis  hos- 
pitals, shows  that  the  diagnosed  consumptive  who  is 
intelligent  and  obedient  can  be  cared  for  under  suit- 
able conditions  without  menacing  the  health  of  others. 
Under  such  conditions  it  is  possible  to  control  tuber- 
culosis not  only  in  hospitals  but  in  the  home.  But 
in  general  we  are  far  from  meeting  the  requirements. 
Frequently  tuberculosis  is  not  diagnosed,  and  this 
fault  may  be  divided  between  the  medical  profession 
and  the  laity.  The  consumptive  may  not  seek  a 
physician  or  he  may  refuse  a  thorough  examination. 
The  physician  may  be  at  fault  in  not  performing  a 


220  HEALTH  AND  DISEASE 

thorough  examination  as  well  as  in  failing  to  detect 
the  disease.  In  this  connection  there  are  several 
rather  complicated  considerations.  The  diagnosis  of 
tuberculosis  may  be  difficult  and  demand  training  and 
equipment  not  possessed  by  many  physicians.  The 
board  of  health  laboratories  which  examine  sputum 
for  tubercle  bacilli  free  of  charge  help  to  ameliorate 
this  difficulty,  but  these  laboratories  are  used  far  too 
little  and  too  often  a  single  negative  sputum  examina- 
tion is  accepted  as  final. 

Again  the  patient  may  be  unable  or  unwilling  to 
pay  for  a  thorough  examination,  particularly  when  he 
feels  convinced  that  the  alleviation  by  drugs  of  a 
troublesome  cough  will  make  him  well.  The  physi- 
cian, perhaps,  cannot  afford  for  a  small  fee  to  spend 
the  time  on  the  thorough  examination  of  all  his  patients, 
particularly  when  he  knows  that  most  of  his  patients 
will  prove  to  be  sound.  The  increased  number  of 
tuberculosis  dispensaries  and  the  various  schemes  for 
encouraging  the  periodic  complete  physical  examina- 
tions in  health  have  not  solved  this  aspect  of  the 
problem.  Such  schemes  reach  only  special  classes  and 
not  the  average  man  or  woman. 

A  further  complication  is  seen  in  the  reluctance  on 
the  part  of  the  physician  and  the  patient's  family  to 
acquaint  the  patient  with  the  disagreeable  truth.  In 
ignorance  the  patient  does  not  benefit  either  himself  or 
the  community  by  the  mere  fact  that  the  diagnosis 
has  been  made.  The  solution  of  the  difficulty  attend- 
ing the  early  diagnosis  of  tuberculosis  lies  exclusively  in 
the  education  of  both  the  medical  profession  and  the 
laity.  To  the  individual  early  diagnosis  means  the  only 
possibility  of  cure ;  to  the  community  early  diagnosis 
means  the  prevention  of  the  spread  of  the  disease. 

Only  the  patient  who  understands  the  possibilities 
of  the  transmission  of  tuberculosis  can  be  trusted  to 


THE  AIR-BORNE  DISEASES 

take  care  of  sputum  and  other  discharges  which 
contain  tubercle  bacilli.  Since  many  other  diseases 
are  spread  in  the  same  way  as  tuberculosis,  it  is  im- 
perative that  as  far  as  possible  all  persons,  whether 
manifestly  diseased  or  not,  should  exercise  reasonable 
precautions.  Habits  firmly  fixed  in  health  can  be 
trusted  in  disease.  Hence  education  concerning  cough- 
ing, promiscuous  spitting,  and  the  use  of  common 
utensils  should  be  universal  and  not  restricted  to  the 
known  consumptives  or  other  disease  carriers.  Many 
persons  are  unrecognized  disease  carriers  and  every 
individual  is  a  possible  disease  carrier  in  the  future. 
The  community  has  an  obvious  duty  in  regard  to  the 
ignorant,  refractory,  or  incorrigible  consumptive,  — 
the  compulsory  segregation  of  such  persons  under  such 
conditions  that  they  cannot  menace  their  fellow  beings. 
In  many  instances  the  conditions  of  the  consumptive 
are  such  that  adequate  precautions  are  impossible. 
The  consumptive  himself  may  be  willing,  but  too  sick. 
The  conditions  of  work  or  living  may  be  such  that 
infection  of  others  is  a  certainty.  Here  we  find  the 
pressing  problem  of  the  home-care  of  the  consump- 
tive in  all  conditions  of  society  except  the  well-to-do. 
A  family  of  seven  in  a  three-room  tenement  furnishes 
conditions  which  preclude  the  exercise  of  satisfactory 
precautions.  The  presence  of  young  children  with 
the  careless  habits  of  childhood  furnishes  an  important 
factor  of  difficulty.  We  have  already  noted  the  fre- 
quency of  tuberculous  infection  in  childhood,  which 
may  be  largely  attributed  to  the  impossibility  of 
eliminating  the  unhygienic  habits  of  children.  Tuber- 
culosis cannot  be  controlled  in  the  conditions  of  pov- 
erty, overcrowding,  and  ignorance.  Ample  statistics 
are  available,  which  show  that  the  institutional  segre- 
gation of  the  advanced  consumptive  is  followed  in  all 
countries  by  a  fall  in  the  death  rate.  The  advanced 


222  HEALTH  AND  DISEASE 

consumptive  daily  expectorates  millions  of  tubercle 
bacilli,  and  he  can  be  controlled  and  the  spread  of  the 
disease  prevented  only  under  the  conditions  which 
have  been  described.  An  important  part  of  the  tuber- 
culosis prevention  work  consists  in  the  increased  ac- 
commodations for  the  advanced  consumptive  in  hos- 
pitals where  adequate  precautions  against  the  spread 
of  the  disease  are  possible. 

Man  is  by  no  means  the  only  carrier  and  source  of 
tubercle  bacilli  and  tuberculosis.  The  disease  occurs 
in  cattle  and  other  mammals,  in  birds,  and  in  some  of 
the  cold-blooded  beasts.  It  is  only  in  cattle,  however, 
that  tuberculosis  of  other  animals  is  of  real  importance 
to  man.  Bovine  tuberculosis  is  caused  by  a  tubercle 
bacillus  which  is  typically  somewhat  different  from 
the  human  tubercle  bacillus.  The  bovine  tubercle 
bacillus  in  its  typical  form  probably  does  not  cause 
consumption,  but  it  is  a  frequent  cause  of  tuberculosis 
of  the  intestines  and  the  peritoneum,  of  glands  (scrofula), 
of  tuberculosis  of  the  spine  (Pott's  disease  and  hump- 
back), of  tuberculosis  of  the  joints  (hip  disease,  white 
swelling),  and  of  fatal  generalized  tuberculosis  with 
tuberculous  meningitis.  Over  one  per  cent  of  beef 
cattle,  over  two  per  cent  of  hogs,  and  five  to  twenty- 
five  per  cent  of  dairy  cattle  show  tuberculosis.  The 
disease  rarely  affects  the  muscles  of  animals,  and,  in 
any  event,  thorough  cooking  will  destroy  the  bacilli 
and  render  the  carcass  entirely  safe  for  human  con- 
sumption. The  main  source  from  which  bovine  tuber- 
cle bacilli  enter  the  human  body  is  milk,  and  in  order 
that  such  bacilli  be  present  in  milk,  it  is  usually  neces- 
sary that  the  cow  have  tuberculosis  of  the  udder. 
Collected  statistics  from  all  parts  of  the  world  show 
the  frequency  of  tubercle  bacilli  in  milk,  the  percentage 
varying  from  five  to  twenty  per  cent.  Butter  is  slightly 
more  frequently  infected  with  tubercle  bacilli. 


THE  AIR-BORNE  DISEASES  223 

The  bovine  infections  in  man  are  essentially  alimen- 
tary in  origin  and  are  largely  restricted  to  childhood 
when  the  diet  is  to  so  large  an  extent  made  up  of  milk. 
This  explains  the  frequency  of  scrofula  (tuberculosis 
of  the  glands  of  the  neck)  and  bone  and  joint  tuber- 
culosis in  children.  Such  tuberculosis  is  not  neces- 
sarily bovine  in  origin,  but  it  probably  is  in  from 
twenty-five  to  fifty  per  cent  of  the  cases.  About  five 
per  cent  of  all  cases  of  tuberculosis  come  from  tuber- 
culous cows,  but  on  account  of  its  usual  localization 
only  one  to  two  per  cent  of  the  mortality  is  due  to 
bovine  tuberculosis.  However,  this  is  a  form  of  the 
disease  which  can  readily  be  prevented.  The  tuber- 
culin test,  while  not  infallible,  is  a  reasonably  accurate 
and  very  useful  method  of  determining  the  existence 
of  tuberculosis  in  cattle.  Under  proper  restrictions 
such  cattle  may  be  used  for  food,  but  the  milk  should 
not  be  used  unless  pasteurized.  If  cows  are  not 
tuberculin  tested,  it  is  probable  that  about  ten  per  cent 
will  have  tubercle  bacilli  in  the  milk.  Periodic,  care- 
ful, and  thorough  inspection  of  dairies  and  cows  by 
trained  veterinarians  and  the  removal  of  all  cows  with 
clinical  tuberculosis  and  with  any  suspicious  abnor- 
malities of  the  udder  will  eliminate  all  danger  of  tuber- 
culosis from  milk.  Such  a  procedure  is  naturally  vio- 
lently opposed  by  many  milk  producers,  but  progress 
is  being  made.  It  is  necessary  to  convince  the  farmer 
that  milk  which  pleases  the  palate  may,  nevertheless, 
cause  disease.  But  the  facts  are  incontrovertible  and 
despite  the  hardships  of  strict  regulations,  which  are 
often  not  uniform  in  different  communities,  it  is  in- 
tolerable that  we  continue  to  drink  tubercle  bacilli 
with  our  milk  and  eat  them  with  our  butter,  when  the 
means  of  eliminating  this  source  of  infection  is  readily  at 
hand.  This  source  of  danger  has  been  underestimated 
for  too  long  a  time,  and  it  can  be  overlooked  no  longer. 


224  HEALTH  AND  DISEASE 

The  second  important  consideration  in  the  preven- 
tion of  tuberculosis  is  the  prevention  of  the  develop- 
ment of  tuberculous  disease  from  tuberculous  infection. 
While  over  half  of  the  population  is  infected  with 
tuberculosis,  only  one-tenth  die  from  it.  The  large 
majority  of  those  infected  never  develop  tuberculous 
disease.  Even  our  most  modern  and  searching  methods 
of  examination,  including  the  X-ray  and  the  tuberculin 
test,  are  quite  inadequate  to  reveal  to  us,  as  a  general 
rule,  the  person  who  is  infected  with  tuberculosis  but 
who  has  not  the  disease.  We  do  not  know  positively 
the  factors  which  determine  the  latency  or  the  activity 
of  the  infection.  We  know,  of  course,  that  the  three 
fundamental  principles  which  govern  all  infections  also 
apply  to  tuberculosis,  namely,  the  amount  of  the  infec- 
tion, the  virulence  of  the  organism,  and  the  resistance 
of  the  individual.  But  long  experience  with  this  dread 
disease  has  given  us  valuable  additional  data.  We 
know  how  frequently  tuberculosis  is  the  cause  of 
death  of  drunkards,  of  prostitutes,  and  of  prize-fighters 
who  no  longer  train  but  indulge  in  various  excesses. 
We  know  that  while  tuberculosis  does  not  spare  the 
rich,  it  is  more  common  among  the  poor.  Recent 
statistics  show  that  the  percentage  of  tuberculosis  is 
over  ten  times  more  frequent  among  the  heads  of 
families  who  earn  less  than  $500  a  year  than  among 
those  who  earn  $700  or  over  a  year.  In  other  words, 
poor  habits  of  hygiene  and  unhealthy  conditions  of 
life,  whether  created  voluntarily  or  by  force  of  circum- 
stances or  by  ignorance,  carry  a  strong  probability 
that  a  quiescent  tuberculous  infection  may  develop 
into  tuberculous  disease. 

Tuberculosis  is  frequently  the  penalty  of  dissipa- 
tion. The  tubercle  bacillus  is  practically  ever-pres- 
ent, so  that  the  lowering  of  bodily  resistance  tends  to 
favor  the  development  of  the  disease.  Hence  tuber- 


THE  AIR-BORNE  DISEASES  225 

culosis  may  be  rightly  called  more  a  social  than  a 
medical  problem.  To  eliminate  tuberculosis  means  to 
eliminate  poverty,  overcrowding,  undernutrition,  over- 
fatigue,  and  lack  of  recreation.  All  this,  of  course, 
involves  a  complete  readjustment  of  our  social  and 
industrial  world.  In  any  event  the  problem  of  tuber- 
culosis cannot  be  separated  from  the  poverty  which 
causes  tuberculosis  and  the  poverty  created  by  it. 
Better  housing,  adequate  food,  better  hours  for  labor 
under  better  conditions,  more  parks,  and  open  air  schools 
are  steps  in  the  right  direction.  But  it  is  even  more 
essential  to  provide  adequate  machinery  by  which 
whatever  knowledge  and  whatever  facilities  for  the 
preservation  of  health  that  we  now  have  may  be  better 
utilized. 

The  Treatment  and  Cure  of  Tuberculosis.  It  must 
be  repeated  that  most  of  us  have  been  infected  with 
tuberculosis  at  some  time  or  other,  although  we  over- 
come the  infection  and  keep  it  under  control.  We 
know  that  poor  health  habits  and  faulty  conditions  of 
life  encourage  the  development  of  the  disease.  Sound 
health  habits  and  faultless  conditions  of  life  restrict 
the  development  of  the  disease  and  create  a  cure. 
Even  so  long  ago  as  Hippocrates  it  was  recognized 
that  consumption  was  curable  if  taken  in  time.  Bod- 
ington,  in  1840,  was  the  first  in  modern  times  to  possess 
sufficient  courage  to  oppose  the  teachings  of  the  day 
and  treat  consumption  with  fresh  air  and  sunlight.  In 
1854,  Brehmer,  himself  a  cured  consumptive,  built  a 
sanatorium  for  consumptives  in  the  Black  Forest  of 
Germany.  In  1883  Dr.  Trudeau,  of  New  York,  who 
had  found  health  in  the  open  air  of  the  Adirondacks, 
established  a  sanatorium  at  Saranac  Lake.  By  this 
time,  through  the  work  of  Koch,  tuberculosis  was 
being  understood  and  consumptives  were  being  cured. 
Sanatoria  were  established  all  over  the  world.  But 


226  HEALTH  AND  DISEASE 

even  now  there  is  much  misunderstanding  concerning 
the  functions  of  sanatoria.  Such  institutions  do  not 
cure  in  the  ordinary  sense;  sanatorium  life  provides 
the  essential  requirements  which  make  a  cure  possible. 
These  requirements,  in  simplest  terms,  are  the  best 
possible  health  habits  and  surroundings  under  compe- 
tent supervision.  The  aim  is  to  put  the  body  in  the 
highest  state  of  efficiency  and  thus  combat  disease. 
This  procedure  is  not  solely  applicable  to  tuberculosis, 
but  it  is  also  applicable  to  any  other  abnormal  condition, 
whether  due  to  infection  or  other  causes,  such  as  exces- 
sive fatigue,  neurasthenia,  and  the  like.  Fresh  air 
and  sunlight,  rest,  which  means  the  conservation  of 
energy  and  the  avoidance  of  fatigue,  and  good  food  in 
abundance  are  only  the  means  to  the  end  of  physical 
efficiency.  It  is  possible  to  secure  these  requirements 
at  home,  but  it  is  usually  easier  to  carry  out  ,  these 
instructions  in  a  sanatorium  under  constant  super- 
vision in  company  with  others,  away  from  the  usual 
distractions  of  the  home  life.  Milk  and  eggs,  so  often 
glorified  in  the  treatment  of  consumption,  merely  mean 
so  many  easily  assimilated  calories.  The  benefits  of 
a  change  of  climate  often  mean  increased  opportu- 
nity for  the  out-of-door  life  and,  sometimes,  freedom 
from  family  cares. 

Statistics  show  that  there  is  no  great  difference  in 
the  percentage  of  recoveries  in  sanatoria  whether  at 
sea  level  or  in  high  altitudes.  The  evidence  indicates 
a  slight  difference,  not  yet  explainable,  in  favor  of  the 
higher  altitudes.  Yet  the  indigent  consumptive,  who 
can  get  rest,  fresh  air,  and  good  food  at  home  at  sea 
level,  will  do  far  better  than  to  endure  loneliness  on 
insufficient  food  in  poor  quarters  at  a  high  altitude. 

Eighty  per  cent  of  the  Consumptives  in  the  early 
stages,  under  proper  treatment,  will  recover,  but  this 
treatment  may  require  months  and  the  exercise  of 


THE  AIR-BORNE  DISEASES  227 

much  fortitude  and  patience.  Furthermore,  after  the 
disease  is  arrested,  much  care  is  frequently  necessary 
to  prevent  the  re-development  of  the  disease.  The 
arrested  case  is  like  the  infected  case  without  the  dis- 
ease, only  much  more  liable  to  redevelop  the  disease. 
Bitter  experience  has  taught  us  to  be  chary  in  the  use 
of  the  word  "  cure  "  in  connection  with  tuberculosis. 
It  is  difficult  or  impossible  to  be  positive  that  the  in- 
fection has  been  permanently  destroyed.  The  cure 
of  a  consumptive  means  more  than  the  saving  of  an 
individual  life;  it  means  the  prevention  of  a  focus 
which  may  spread  the  infection. 

In  order  that  a  consumptive  may  have  four  chances 
out  of  five  to  recover,  his  disease  must  be  discovered 
in  the  early  stage_s.  Therefore,  the  public  at  large, 
all  liable  to  this  disease,  must  understand  the  necessity 
of  seeking  medical  advice  concerning  a  persistent  cough, 
chest  pains,  fevers,  unexplained  loss  of  weight,  and 
other  possible  symptoms  of  tuberculosis.  In  addition 
the  medical  profession  must  possess  the  training  and 
equipment  for  early  diagnosis.  Only  by  systematic 
and  widespread  education  can  this  be  brought  about. 

Since  consumption  is  such  a  universal  disease,  it 
inevitably  follows  that  cures  of  all  sorts  are  everywhere 
recommended.  Many  things  may  contribute  to  re- 
covery. Tuberculin  in  skilled  hands,  in  selected  cases, 
lung  compression  under  the  same  conditions,  the  wise 
use  of  drugs,  may  all  be  of  value.  But  none  of  these 
means  is  essential.  There  is  no  specific  cure.  There 
are  those  who  chase  such  cures.  Those  that  move 
from  climate  to  climate,  from  sanatorium  to  sanato- 
rium, from  doctor  to  doctor  make  up  a  small  army  and 
they  are  well  described  as  "  tuberculous  tramps." 
Instead  of  finding  the  sure  and  quick  cure,  they  have 
lost  the  opportunity  which  too  often  comes  but  once 
and  is  soon  gone. 


228  HEALTH  AND  DISEASE 

Tuberculosis  and  Housing.  Prolonged  proximity 
with  consumptives  is  obviously  of  great  danger,  and 
such  proximity  usually  obtains  in  houses.  Of  course, 
as  a  rule,  the  factor  which  compels  crowding  is  poverty. 
Investigation  in  all  large  cities  shows  tenement  blocks 
in  which  there  is  an  average  of  over  two  persons  per 
room.  Under  such  circumstances,  granted  a  consump- 
tive, the  spread  of  the  disease  is  almost  inevitable. 
Berlin  statistics  in  1907  showed  that  in  only  sixteen 
per  cent  of  over  6,000  persons  dying  of  tuberculosis 
did  the  family  occupy  a  home  of  three  rooms  or  more. 

In  Edinburgh  Philip  found  that  in  sixty-six  per  cent 
of  the  cases,  the  affected  persons  slept  in  the  same  room 
with  one  or  more  members  of  the  family,  and  in  eleven 
per  cent  more  than  one  more  occupied  the  same  room. 
Such  conditions  also  explain  the  fact  that  the  infection 
in  tuberculosis  is,  as  a  rule,  received  in  childhood. 

Miss  La  Motte,  in  Baltimore,  found  that  seventy- 
three  per  cent  of  a  group  of  consumptive  children  came 
from  homes  in  which  there  was  already  tuberculosis. 
Mac  Corrison  and  Burns,  in  Massachusetts,  found  134 
instances  of  family  clusters  of  three  or  more  in  a  study 
of  1,300  cases.  Three  houses  in  New  York  have 
records  of  37,  25,  and  19  cases  respectively  within 
nine  years.  Another  example  of  this  condition  is  that 
of  a  well-known  man  who  moved  away  from  home  early 
in  life.  His  parents,  and  all  his  brothers  and  sisters 
remained  in  the  little  old  homestead  and  one  by  one 
died  of  consumption.  The  homestead  at  last  reverted 
to  the  only  member  of  the  family  who  moved  away 
and  who  alone  escaped  tuberculosis.  He  had  the  house 
burned.  In  such  a  house  consumption  was  mainly 
spread  by  the  constant  presence  of  a  consumptive,  but 
the  rather  hardy  tubercle  bacilli  might  well  infest 
every  dark  nook  and  corner,  and,  due  to  the  long-con- 
tinued extensive  infection  of  every  article  in  the  house, 


THE  AIR-BORNE  DISEASES  229 

the  certain  destruction  of  all  the  infecting  organisms 
would  be  difficult.  Probably  ninety  per  cent  of 
tuberculous  infection  of  human  origin  takes  place  in 
the  living  rooms  of  the  house.  The  incapacitated 
consumptive  often  remains  at  home.  He  may  do 
light  work  at  home  or  to  him  may  fall  the  task  of  car- 
ing for  the  children.  It  is  certain  that  in  the  past  we 
have  not  appreciated  the  importance  of  home  infec- 
tion and  the  danger  to  children.  Under  proper  con- 
ditions adequate  precautions  can  be  taken  at  home, 
but  the  control  of  the  consumptive  at  home  is  made 
more  difficult  by  the  presence  of  children. 

Tuberculosis  and  Occupation.  Volumes  could  be 
written  on  the  relation  of  tuberculosis  and  poverty. 
For  poverty  furnishes  all  the  surroundings  favorable 
not  only  to  infection  with  tuberculosis  but  also  for  its 
development  after  the  individual  is  infected.  It  is 
difficult  to  disassociate  many  occupations  from  the 
accompanying  poverty  so  common  in  them.  Statistics 
show  that  certain  trades  have  a  high  mortality  from 
tuberculosis.  The  so-called  dusty  trades,  including 
the  out-of-door  quarryman,  show  mortality  from  tuber- 
culosis that  is  far  above  the  average  from  all  occupa- 
tions. The  factor  here  seems  to  be  the  irritation  of 
the  lungs  which  favors  not  only  infection  but  also 
development.  Out-of-door  occupations  in  general  show 
a  relatively  low  tuberculosis  mortality. 

As  might  be  expected  tuberculosis  is  rife  among  the 
poorly  paid  indoor  trades.  On  the  other  hand,  one 
may  be  surprised  to  learn  that  tuberculosis  is  the  cause 
of  more  than  half  the  deaths  among  stenographers 
and  school  teachers.  The  high  incidence  of  tubercu- 
losis here  cannot  be  attributed  to  any  peculiarity  of  the 
work,  but  to  the  general  habits  of  living.  It  is  not 
only  the  indoor  work  but  the  general  faulty  hygiene 
of  life  and  surroundings  which  determine  this  high 


230  HEALTH  AND  DISEASE 

mortality.  A  dusty  occupation  undoubtedly  favors 
tuberculous  infection  and  the  development  of  consump- 
tion. In  all  other  occupations  the  ordinary  factors  of 
health  and  hygiene,  that  is,  overcrowding,  fatigue,  bad 
air,  and  the  like,  merely  play  their  proportionate  part 
in  the  daily  total  of  the  individual's  health  habits 
and  conditions  of  life. 

Conclusions.  It  is  becoming  increasingly  evident 
that  the  problem  of  tuberculosis  in  its  entirety  is  too 
great  for  private  enterprise.  The  problem  is  medical, 
social,  and  economic.  Even  in  the  aspects  which  are 
mainly  medical,  uniform  public  action  and  new  legis- 
lation are  necessary.  Only  by  the  concerted  thorough 
covering  of  the  entire  field  of  human  activity  can  tuber- 
culosis be  controlled.  No  tuberculosis  program  is 
adequate  which  does  not  include  the  following  items. 

1.  Sanatorium  provision  for  the  treatment  and  cure 
of  early  cases.     Sanatoria  are  entirely  inadequate  in 
this  country.     Germany  has  solved,  to  some  extent 
at  least,  the  financial   problem  of   the   erection   and 
maintenance  of  sanatoria  by  obligatory  health  insur- 
ance.    This   problem   of   health    insurance   is    slowly 
coming  to  the  fore  in  the  United  States,  but  the  deci- 
sion, unfortunately,  lies  in  the  field  of  politics. 

2.  Hospital  accommodation  for  the  advanced  con- 
sumptive.    This  is  largely  for  the  protection  of  the 
community,  but,  happily,  some  advanced  consumptives 
will  always  recover. 

3.  Facilities  for  the  early  diagnosis  of  tuberculosis. 
This    will    include    tuberculosis    dispensaries    and    all 
methods  of  the  periodic  routine  physical  examination 
of  all  persons,  in  order  to  detect  all  cases  of  tubercu- 
losis.    Readily  available  laboratories  are  also  impor- 
tant. 

4.  The  collection  and  use  of  vital  statistics.     This 
includes  not  only  the  reporting  of  all  cases  of  illness 


THE  AIR-BORNE  DISEASES  231 

and  death  from  tuberculosis,  but  the  investigation  of 
these  cases.  For  example,  in  Berlin  the  systematic 
examination  of  the  4,500  new  cases  of  consumption 
revealed  4,500  unrecognized  cases  of  tuberculosis, 
most  of  which  were  in  an  early  and  favorable  stage  for 
treatment.  Furthermore,  the  source  of  the  infection 
must  be  discovered  and  stopped  forever,  if  possible. 

5.  Care  of  the  health  of  children.     The  infection 
usually  takes  place  in  childhood. 

6.  Improvement  in  the  general  hygienic  habits  and 
the  sanitary  conditions,  especially  in  the  homes. 

7.  The  education  of  the  public  and  of  the  medical 
profession.     Regulations  and  legislation  will  be  use- 
less unless  there  is  an  intelligent  application  of  the 
known  facts. 

Only  a  few  visionaries  foresee,  in  any  immediate 
future,  the  stamping  out  of  tuberculosis.  The  infec- 
tions which  are  transmitted  by  droplets  and  in  the  air 
are  difficult  of  eradication,  as  we  know  from  experi- 
ence with  measles  and  scarlet  fever.  The  difficulty 
of  making  an  early  diagnosis  often  presents  an  obstacle. 
Furthermore,  the  incidence  of  tuberculosis  is  closely 
interwoven  with  our  present  social  and  economic 
status.  Nevertheless,  despite  these  difficulties,  it  is 
possible  to  accomplish  much  in  the  prevention  of  this 
disease,  the  greatest  scourge  of  civilization,  and  in  this 
belief  we  get  encouragement  from  the  considerable 
diminution  of  the  disease  already  achieved  by  the  ap- 
plication of  the  discoveries  of  science. 

Cerebro-Spmal  Meningitis 

Epidemic  cerebro-spinal  meningitis  is  caused  by  a 
bacterium  of  the  coccus  group  —  the  meningococcus. 
There  are  still  other  forms  of  meningitis  which  are  due 
to  other  organisms,  and  the  diagnosis  is  only  made 


232  HEALTH  AND  DISEASE 

with  certainty  by  the  examination  of  the  spinal  fluid 
after  "  lumbar  puncture." 

Cerebro-spinal  meningitis  has  been  known  in  epi- 
demics for  centuries.  The  disease  is  an  inflammation 
of  the  lining  membranes  of  the  brain  and  spinal  cord, 
a  condition  which  not  so  long  ago  was  extremely  fatal. 
The  mortality,  while  varying  in  different  epidemics, 
was  always  from  sixty  to  eighty  per  cent.  Now  we 
have  a  most  effective  antitoxic  serum  which  is  produced 
by  the  immunization  of  a  horse.  This  serum  is  of  little 
value  when  injected  subcutaneously,  so  that  to  be 
effective  it  must  be  applied  directly  to  the  inflamed 
meninges,  i.e.  by  injection  into  the  spinal  canal. 
Through  the  use  of  the  anti-meningococcus  serum  the 
mortality  of  the  disease  has  been  reduced  to  under 
twenty  per  cent  and  there  are  fewer  complications 
than  before  the  serum  was  discovered. 

The  exact  method  of  spread  of  cerebro-spinal  menin- 
gitis is  not  known,  although  we  have  learned  the 
following  facts.  The  meningococcus  has  slight  vitality 
outside  of  the  body,  and  the  disease  is  most  prevalent 
at  the  time  that  the  other  air-borne  diseases  are  prev- 
alent. While  the  disease  seems  to  be  largely  localized 
in  the  lining  of  the  brain  and  spinal  cord,  virulent 
meningococci  are  found  in  the  mucous  membranes  of 
the  nose  and  throat  and  in  their  secretions,  not  only  in 
the  human  but  in  the  experimental  disease.  Further- 
more, a  proportion  of  persons  harbor  these  organisms 
without  ever  having  the  disease.  It  seems  probable, 
therefore,  that  the  transfer  is  effected  by  the  droplet 
method  of  infection,  presumably  through  the  sick  and 
through  carriers.  Isolation  and  quarantine  of  such 
persons  is,  of  course,  necessary,  and  thorough  disin- 
fection of  the  nasal  secretions  of  the  sick  should  be 
carried  out.  Since  exposure  is  only  very  irregularly 
followed  by  the  disease  and  since  the  administration 


THE  AIR-BORNE  DISEASES  233 

of  anti-meningococcus  serum  must  be  by  lumbar  punc- 
ture, the  serum  is  rarely  used  as  a  preventive  measure. 

Smallpox 

Smallpox  is  a  highly  infectious  disease  in  which  the 
mortality  varies  from  one  to  fifty  per  cent,  but  the 
average  in  the  unvaccinated  is  about  thirty  per  cent. 
The  cause  is  undoubtedly  some  sort  of  a  micro-organ- 
ism, which  still  remains  undiscovered.  The  infection 
is  probably  carried  largely  in  droplets  from  the  nose 
and  throat  of  the  sick  to  other  persons.  Infection 
through  the  skin  is  possible.  Smallpox  is  a  self- 
limited  disease  and  there  is  no  specific  cure. 

History  of  Smallpox.  Smallpox  seems  to  have 
been  known  in  India  and  China  from  time  immemorial. 
Ebers  believes  that  he  has  found,  in  the  papyrus  which 
bears  his  name,  a  reference  to  the  existence  of  smallpox 
in  ancient  Egypt  (about  3700  B.C.).  Throughout 
classical  and  medieval  times  references  to  the  occur- 
rence of  smallpox  are  comparatively  numerous.  In 
the  sixth  century  of  the  Christian  Era,  Bishop  Marius, 
of  Lusanne,  and  Gregory,  of  Tours,  wrote  of  epidemics 
of  smallpox  sweeping  over  Italy  and  France,  thus  giv- 
ing the  first  positive  references  to  the  disease.  The 
oldest  known  medical  account  of  this  scourge  seems 
to  be  that  of  the  Arabian  writer  Rhazes  in  the  tenth 
century.  In  more  modern  times  there  are  records  of 
epidemics  of  smallpox  in  almost  all  parts  of  the  civ- 
ilized world.  The  disease  is  said  to  have  been  intro- 
duced into  America  (1520)  by  a  negro  who  accompanied 
Cortez  on  his  expedition  into  Mexico.  It  appeared 
among  the  New  England  Indians  in  1633  and  since 
that  time  America  has  never  been  free  from  smallpox. 
It  is  estimated  that  from  1700  to  1800  an  average 
of  760,000  persons  died  from  smallpox  each  year 


£34  HEALTH  AND  DISEASE 

throughout  Europe.  It  was  a  proverbial  saying  "  that 
few  escaped  smallpox  and  love." 

No  historical  fact  is  better  established  than  that 
before  the  discovery  of  vaccination  smallpox  was  one 
of  the  most  fatal  and  dreaded  scourges  of  mankind. 
So  widespread  was  the  disease  that,  as  Macaulay  in- 
forms us,  it  was  a  rare  thing  at  one  time  to  find  a  per- 
son in  London  not  disfigured  by  smallpox.  To  have 
had  smallpox  was  a  valuable  recommendation  in  seek- 
ing employment.  An  advertisement  of  the  eighteenth 
century  reads :  "  A  parcel  of  likely  negro  women  and 
girls,  13  to  21  years  of  age,  who  have  all  had  small- 
pox, were  lately  imported."  The  experience  of  the 
city  of  Boston  is  illuminating  of  the  conditions.  The 
population  at  the  time  of  the  epidemic  was  15,684.  Of 
these  5,998  had  had  the  disease.  During  the  epidemic 
5,545  contracted  the  disease,  while  2,124  were  inocu- 
lated with  it;  1,843  left  town,  so  that  there  were 
in  the  city  only  174  persons  who  had  never  had 
smallpox. 

Before  the  introduction  of  vaccination  smallpox  was 
more  common  than  measles,  and,  on  account  of  its 
infectivity,  people  usually  contracted  it  in  childhood. 
One-tenth  of  all  deaths  were  due  to  smallpox,  and  in 
years  of  epidemics  it  was  the  cause  of  half  the  deaths. 
More  than  half  of  the  living  carried  the  scars  of  small- 
pox and  blindness  was  a  frequent  result. 

Now,  little  more  than  a  hundred  years  later,  com- 
paratively few  people  in  this  country  ever  see  smallpox 
and  the  story  of  this  scourge  has  come  to  be  almost 
legendary.  In  our  present-day  security  many  people 
have  come  to  doubt  the  dangers  from  this  disease  and 
even  maintain  that  it  is  extinct.  Yet  in  the  United 
States  there  are  approximately  70,000  cases  yearly. 
Over  30,000  cases  were  reported  in  the  registration  area 
during  1914.  In  many  of  the  Western  states  smallpox 


THE  AIR-BORNE  DISEASES  235 

is  present  continuously.  From  1893  to  1898  the 
number  of  deaths  from  smallpox  in  Russia,  including 
Asiatic  Russia,  was  275,502.  In  Spain,  during  the 
same  period,  there  were  nearly  25,000  deaths,  and 
Hungary,  Italy,  and  Austria  each  had  about  10,000 
deaths.  Smallpox  is  still  rampant  in  the  Far  East 
and  the  severity  of  the  disease  and  its  highly  infectious 
nature  is  similar  to  that  of  a  hundred  years  ago  in 
Europe.  Epidemics  have  been  recorded  in  Illinois  as 
recently  as  1901-02 ;  in  St.  Paul,  1899-1900  ;  in  Michi- 
gan, 1912 ;  in  Topeka,  Kansas,  1911 ;  in  London, 
1901-02,  and  in  Montreal,  1902. 

Vaccination.  While  it  is  true  that  general  sanita- 
tion and  hygiene  have  improved  greatly,  this  improve- 
ment has  not  materially  affected  the  mortality  curve 
of  measles,  whooping  cough,  and  scarlet  fever,  which 
can  be  fairly  compared  to  smallpox  both  in  their  method 
of  transmission  and  their  infectiousness.  One  factor, 
and  one  factor  alone,  has  brought  about  this  prodigious 
change  in  the  so-called  civilized  countries.  That 
factor  is  vaccination.  Everywhere  the  prevalence  of 
smallpox  is  in  direct  proportion  to  the  frequency  of 
vaccination.  In  well-vaccinated  Germany  smallpox 
is  practically  unknown.  In  the  United  States  about 
one-tenth  of  the  population  is  unvaccinated,  hence  the 
70,000  cases  yearly.  This  failure  to  be  vaccinated  is 
not  peculiar  to  any  one  class  of  the  population,  since 
five  per  cent  of  the  students  in  the  first  year  at  Harvard 
College  are  unvaccinated.  Furthermore,  there  is  no 
record  of  a  single  instance  where  thorough  vaccination 
did  not  completely  stop  an  epidemic. 

The  story  of  vaccination  is  an  interesting  one.  Al- 
though discovered  in  the  last  years  of  the  eighteenth 
century,  it  was  not  understood  at  all  until  the  work  of 
Pasteur  over  fifty  years  later.  Even  to-day,  in  spite 
of  the  extensive  use  of  vaccination,  we  do  not  know 


236  HEALTH  AND  DISEASE 

the  actual  infective  agent  of  either  the  vaccine  or  small- 
pox. But  the  statistics  of  over  a  century  have  demon- 
strated its  efficiency,  although  we  are  denied  full 
knowledge  of  its  action.  The  efficiency  of  vaccination 
against  smallpox  has  been  so  striking  that  the  dis- 
covery of  other  vaccines  equally  effective  against  other 
scourges  has  been  the  dream  of  many  medical  scien- 
tists and  the  goal  of  then*  labors.  Pasteur  believed 
that,  since  each  infectious  disease  is  caused  by  its  own 
peculiar  organism,  there  could  be  a  vaccine  for  each 
disease.  Pasteur  himself  developed  an  effective  vac- 
cine against  anthrax  and  another  against  hydrophobia 
(rabies),  which  protected  even  after  the  disease  had 
gained  entrance.  Since  his  time  we  have  obtained  a 
vaccine  against  typhoid  fever.  Nevertheless  the  most 
applicable  and  most  effective  vaccination  which  we 
have  to-day  is  that  against  smallpox. 

The  principle  of  vaccination  is  simple  in  the  ex- 
treme. A  single  attack  of  certain  diseases  confers  on 
the  victim  an  immunity  for  life  against  that  disease. 
This  principle  has  been  recognized  since  the  earliest 
times.  Frequently  in  the  past,  and  occasionally  even 
to-day,  parents  deliberately  expose  their  children  to 
mild  cases  of  certain  diseases.  Since,  to  then*  mind,  the 
child  must  almost  inevitably  contract  the  disease,  it  is 
better  to  contract  a  mild  attack  and  secure  immunity 
than  to  run  the  risk  of  a  later  and  more  severe  attack. 
Unfortunately,  while  there  are  frequently  mild  epidem- 
ics of  any  disease,  it  does  not  follow  that  the  disease 
deliberately  contracted  from  a  mild  case  will  be  mild. 
In  addition  such  a  practice  spreads  the  disease.  Small- 
pox has  been  contracted  deliberately  in  this  way  for 
this  purpose  from  the  earliest  times.  Centuries  before 
Christ  this  was  a  common  practice  in  China  and  India. 
The  procedure  usually  consisted  in  taking  a  pustule  of 
a  patient  with  a  mild  form  of  smallpox  and  transferring 


THE  AIR-BORNE  DISEASES  237 

that  pustule  to  a  scratch  on  the  arm  of  a  second  person. 
This  practice  was  known  as  inoculation.  Inoculation 
was  passed  from  one  inoculated  person  to  another. 
Obviously,  in  such  a  procedure,  other  diseases  besides 
smallpox  could  also  be  transferred.  But  the  practice 
of  inoculation  had  much  to  commend  it  for  the  result- 
ing mortality  was  less  than  one  per  cent,  while  the 
mortality  from  virulent  smallpox  was  many  times 
higher. 

But  inoculation,  though  effective,  actually  spread 
smallpox  in  a  mild  form  and  some  of  the  cases  became 
virulent  and  started  severe  epidemics.  In  1770  Ed- 
ward Jenner  heard  a  farmer's  daughter  say,  on  being 
told  that  smallpox  had  broken  out  in  the  neighborhood, 
"  I  cannot  take  that  disease  for  I  have  had  the  cow- 
pox."  Dairymen  had  noted  that  persons  infected 
from  sores  on  the  udders  of  cows,  known  as  "  cowpox", 
escaped  smallpox.  Jenner  substantiated  this  belief 
by  careful  statistics,  and  on  May  14,  1796,  he  did  his 
first  vaccination  on  a  lad  with  virus  taken  from  a  sore 
on  the  hand  of  a  milkmaid  accidentally  infected  while 
milking  a  cow.  The  boy  did  not  take  smallpox,  al- 
though he  was  repeatedly  exposed  to  the  disease.  In 
1798  Jenner  published  his  work. 

Vaccination  was  introduced  into  America  in  1800 
by  Dr.  Benjamin  Waterhouse.  He  vaccinated  his 
children  and  sent  them  into  a  smallpox  hospital,  thus 
establishing  the  fact  that  they  resisted  the  disease. 

Since  1800  vaccination  has  been  carried  to  all  parts 
of  the  world  and  always  with  the  same  result,  —  the 
eradication  of  smallpox.  The  collected  statistics  and 
the  attendant  researches  have  told  us  much  about 
smallpox  and  vaccination,  and  the  following  facts  are 
now  well  established.  Vaccination  to  be  effective 
must  "  take  ",  i.e.  must  leave  a  typical  scar.  After 
a  successful  vaccination  the  person  is  usually  completely 


238  HEALTH  AND  DISEASE 

immune  for  a  period  of  years,  averaging  seven  to  ten. 
If  the  disease  is  contracted,  it  will  be  mild  and 'with 
a  low  mortality.  Vaccination  and  re-vaccination  after 
about  ten  years  will  give  immunity  for  life.  Labora- 
tory investigations  have  shown  that  cowpox  is  really 
identical  with  smallpox,  being  only  a  mild  modifica- 
tion of  smallpox.  Vaccination  from  animals  like 
calves  is  much  preferable  to  transfer  from  human  being 
to  human  being.  Calf  vaccine  cannot  transfer  most 
of  the  human  diseases,  since  the  calves  are  not  sus- 
ceptible to  them,  this  being  particularly  true  of  syphilis. 
If  the  calves  are  properly  cared  for  and  are  subjected 
to  the  tuberculin  test,  the  danger  of  the  transmission 
of  bovine  diseases  is  eliminated. 

Since  in  the  United  States  the  Public  Health  Serv- 
ice inspects  all  vaccines,  there  is  great  security  in 
their  use.  In  Massachusetts  a  wise  State  Board  of 
Health  has  for  years  furnished  free  a  pure  vaccine  virus 
of  its  own  make.  The  vaccination  scratch  is,  of  course, 
subject  to  the  same  infections  as  any  other  scratch, 
but  the  use  of  the  usual  surgical  precautions  will  re- 
move any  danger  of  infection.  Statistics  of  vacci- 
nations under  every  and  all  circumstances  show  one 
fatal  infection  to  65,000  vaccinations.  In  the  Philip- 
pine Islands,  however,  3,500,000  persons  were  vac- 
cinated without  a  death. 

Strange  to  say,  in  the  face  of  this  evidence  the  anti- 
vaccinationists  and  anti-vaccination  societies  exist. 
The  opponents  of  vaccination  generally  dwell  on  the 
following  points.  In  the  first  place  they  point  to  the 
large  use  of  animals  and  object,  further,  to  the  ad- 
ministration of  disease  material  from  animals  to  human 
beings.  It  may  be  granted  that  the  use  of  animals  for 
such  purposes  may  be  repugnant  and  can  only  be 
justified  by  public  necessity.  Confessedly  it  would 
be  much  better  if  the  vaccine  virus  could  be  prepared 


THE  AIR-BORNE  DISEASES  239 

in  a  test  tube,  but  that  is  impossible  at  present.  Like- 
wise, no  one  is  vaccinated  by  choice,  but  it  is  neces- 
sary for  the  community,  and  most  people,  therefore, 
submit  with  good  grace,  particularly  in  view  of  the 
negligible  danger  and  the  enormous  protection  afforded. 

The  second  point  brought  up  by  those  opposed  to 
vaccination  deals  with  the  dangers  of  the  procedure. 
Cases  of  syphilis,  tuberculosis,  tetanus,  and  other 
infections  are  recounted.  The  answer  is  simply  that 
the  careful  use  of  a  proper  vaccine  virus  is  attended 
with  no  dangers.  Gross  carelessness  will  infect  the 
scratch  wound,  but,  at  the  worst,  the  danger  is  less 
than  that  from  scratches  from  pins  and  splinters. 

The  third  point  questions  the  accuracy  of  the  sta- 
tistics and  the  efficacy  of  vaccination.  Emphasis  is 
laid  on  the  improvements  in  hygiene  and  sanitation. 
It  is  true,  due  partly  to  the  activity  of  those  opposed 
to  vaccination,  that  vaccination  is  imperfectly  carried 
out  in  most  countries.  But  we  have  in  Germany 
not  only  vaccination  properly  carried  out  but  also  an 
illustration  of  the  uselessness  of  other  methods  in 
combating  smallpox.  At  first  smallpox  was  combated 
in  Germany  by  rigid  quarantine,  isolation,  and  disin- 
fection with  the  best  German  thoroughness.  Never- 
theless smallpox  raged  as  before.  In  1874  Germany 
passed  the  vaccination  and  re-vaccination  law  which 
required  vaccination  at  birth  and  then  again  in  the 
early  teens.  The  result  has  been  no  epidemics  and 
very  few  fatalities,  and  these  almost  exclusively  among 
immigrants  who  had  never  been  vaccinated.  In  the 
German  army  up  to  the  time  of  the  European  War 
there  had  been  only  two  deaths  from  smallpox  since 
1874,  and  one  of  these  had  never  been  vaccinated 
successfully.  It  is  instructive  to  contrast  the  condi- 
tions where  vaccination  is  enforced  and  where  anti- 
vaccinationists  are  influential.  From  1901  to  1910 


240  HEALTH  AND  DISEASE 

there  were  in  all  Germany  only  380  deaths  from  small- 
pox and  most  of  these  cases  came  from  outside,  but 
during  the  same  period  in  England  and  Wales  with 
half  the  population  of  Germany  there  were  4,286 
deaths  from  smallpox.  Statistics  fail  to  show  any 
great  reduction  in  measles  or  scarlet  fever  which  are 
transmitted  like  smallpox  and  which  are,  on  the  whole, 
less  infectious. 

The  vaccination  history  of  the  victims  of  any  epi- 
demic of  smallpox  always  makes  interesting  reading 
although  it  is  always  monotonously  the  same.  In  an 
epidemic  in  Chicago,  1899-1901,  there  were  310  cases 
of  the  disease.  Of  these,  271  had  never  been  vac- 
cinated successfully;  only  five  had  typical  scars;  the 
other  scars  were  doubtful.  The  most  recent  vacci- 
nation of  the  thirty-nine  who  had  been  vaccinated  was 
sixteen  years  before.  We  have,  further,  the  evidence 
of  the  doctors  and  nurses  who  care  for  smallpox  pa- 
tients and  never  contract  the  disease,  since  they ,  are 
always  well  vaccinated.  Doctors  and  nurses,  who  care 
for  measles  and  scarlet  fever  and  who  are  not  immune 
through  previous  attacks,  not  infrequently  contract 
the  disease  in  the  course  of  their  duty. 

In  most  civilized  countries  the  story  of  smallpox  is 
something  as  follows.  There  are  vaccination  laws 
which  a  proportion  of  the  population  obey,  —  in  the 
United  States  about  nine-tenths.  The  vaccinated 
nine-tenths  generally  protect  the  unvaccinated  one- 
tenth.  Re-vaccination  and,  in  some  cases,  vaccination, 
is  only  done  at  times  of  epidemics.  The  result  is  that 
smallpox  is  constantly  with  us.  If  vaccination  and 
re-vaccination  were  carried  out  among  our  population 
and  all  immigrants  were  vaccinated,  smallpox  would 
disappear  from  this  country.  But  man's  nature  is 
such  that  he  is  forgetful  of  anything  beyond  his 
present  troubles.  Even  incomplete  vaccination  has 


THE  AIR-BORNE  DISEASES  241 

protected  him  from  a  widespread  scourge.  Hence  the 
tendency  is  to  relax  our  already  somewhat  inadequate 
vaccination  laws  rather  than  to  stiffen  them. 

This  lamentable  tendency  gained  such  headway  in 
England  that  not  only  were  the  vaccination  laws  rather 
overlooked,  but  the  supporters  of  vaccination  were 
subjected  to  violent  personal  abuse.  Finally,  in  exas- 
peration, Sir  William  Osier,  long  a  foremost  physician 
in  the  United  States  and  now  Regius  Professor  of 
Medicine  at  Oxford  University,  made  the  following 
statement  in  the  course  of  an  account  of  the  benefits  to 
man  of  science : 

**I  would  like  to  say  a  word  or  two  on  one  of  the 
most  terrible  of  all  acute  infections,  the  one  of  which 
we  first  learned  the  control  through  the  work  of  Jenner. 

"  I  do  not  see  how  any  one  who  has  gone  through 
epidemics  as  I  have,  or  who  is  familiar  with  the  his- 
tory of  the  subject,  and  who  has  any  capacity  left  for 
clear  judgment,  can  doubt  its  value.  Some  months 
ago,  I  was  twitted  by  the  editor  of  the  Journal  of  the 
Anti-vaccination  League  for  *  a  curious  silence '  on 
this  subject.  I  would  like  to  issue  a  Mount  Carmel- 
like  challenge  to  any  ten  un vaccinated  priests  of  Baal. 
I  will  go  into  the  next  severe  epidemic  with  ten  selected 
vaccinated  persons  and  ten  selected  unvaccinated  per- 
sons. I  would  prefer  to  choose  the  latter,  —  three 
members  of  Parliament,  three  anti-vaccination  doc- 
tors, if  they  can  be  found,  and  four  anti-vaccination 
propagandists.  And  I  will  make  this  promise  —  neither 
to  jeer  nor  to  jibe  when  they  catch  the  disease,  but  to 
look  after  them  as  brothers,  and  for  the  four  or  five 
who  are  certain  to  die  I  will  try  to  arrange  the  funerals 
with  all  the  pomp  and  ceremony  of  an  anti-vaccination 
demonstration. ' ' 

Needless  to  say  that  this  challenge  which  sums  up 
so  excellently  the  case  for  vaccination  has  never  been 
answered. 


CHAPTER  XIII 

DISEASES  TRANSMITTED  BY  CONTACT 

THE  group  of  contact  diseases  includes  those  in  which 
the  avenue  of  entrance  of  the  disease  is  at  the  point  of 
contact,  usually  the  skin,  more  rarely  the  mucous 
membranes.  It  is  possible  to  propagate  by  contact 
with  the  mucous  membranes  of  the  mouth  most  of 
the  infections  usually  transmitted  through  the  air, 
mainly  by  droplets,  and  some  of  the  infections  usually 
transmitted  in  food  and  drink.  In  the  first  instance 
the  avenue  of  infection  is,  in  the  main,  from  and  to  the 
respiratory  tract;  in  the  second  case,  the  avenue  of 
infection  is  from  and  to  the  digestive  tract.  But 
there  are  a  number  of  infections  in  which  the  precise 
method  of  infection  varies,  although  it  is  characteristic 
of  them  that  the  avenue  of  entrance  is  through  the  skin 
or,  rarely,  through  the  mucous  membrane. 

Local  Sepsis 

Boils,  for  instance,  are  transmitted  only  by  the 
direct  implantation  of  the  particular  organism  within 
the  skin.  Boils  are  caused  by  a  micrococcus,  the 
staphylococcus.  These  staphylococci  are  common  or- 
ganisms which  are  constantly  on  the  surface  of  the 
skin  awaiting  a  chance  to  get  deeper  into  the  skin 
and  cause  a  lesion,  which,  if  small,  is  a  pimple,  if  larger, 
is  called  a  furuncle  or  boil,  and,  if  still  larger,  is  known 
as  a  carbuncle.  Boils  simply  represent  one  type  of 

242  ' 


DISEASES  TRANSMITTED  BY  CONTACT    243 

skin  infection  which  is  spread  only  by  contact.  The 
infection  in  these  cases  is  usually  carried  into  the  deeper 
structures  along  the  hair  follicles.  The  pus  from  these 
boils  contains  many  organisms  and  the  infection  may 
be  carried  from  place  to  place  in  the  same  person  or 
to  another  person.  The  intact  skin  offers  no  avenue 
of  entrance,  but  small  abrasions  are  very  common, 
especially  at  the  hair  follicles.  The  resistance  to  these 
skin  infections  varies  widely  in  different  individuals 
and  in  the  same  individual  at  different  times.  A 
large  number  of  skin  infections  are  spread  in  the  same 
way  as  boils.  "  Red  flap  "  is  caused  by  a  ringworm 
which  is  really  a  vegetable  bacterium.  This  disease  is 
highly  contagious  by  contact.  The  same  is  true  of  all 
the  parasitic  skin  diseases.  These  conditions  have 
already  been  discussed  in  the  chapter  relating  to  the 
hygiene  of  the  skin. 

Many  diseases  are  caused  by  contact  through  wounds, 
which  include  not  only  the  wounds  in  accidents,  but 
also  those  from  surgical  operations.  Before  the  time 
of  Pasteur,  surgical  operations  were  usually  followed 
by  infections.  Now  we  have  almost  eliminated  in- 
fection after  surgical  operations.  Childbed  or  puer- 
peral fever,  now  happily  nearly  extinct,  is  due  to 
the  introduction  of  bacteria  into  the  womb,  usually 
by  hands  or  instruments.  The  deaths  after  criminal 
operations  are  usually  due  to  the  use  of  unclean 
instruments. 

We  are  all  familiar  with  the  formation  of  pus  or 
matter  after  pin-pricks  and  abrasions  of  the  skin. 
Usually  such  conditions  are  not  serious,  but  general 
sepsis  or  blood-poisoning,  as  it  is  often  called  (not  to 
be  confused  with  the  blood-poisoning  of  syphilis),  may 
result.  A  neglected  pin^prick,  a  crack  in  the  skin  of 
the  foot,  which  is  infected,  the  paring  of  corns  with  an 
unclean  instrument  have  all  resulted  in  the  loss  of 


244  HEALTH  AND  DISEASE 

limb  or  of  life  from  general  sepsis.  The  bacteria  may 
be  present  on  the  skin.  But  the  hands  and  the  finger- 
nails are  almost  constant  carriers  of  these  pus  organisms 
unless  they  are  carefully  cleaned. 

In  general,  all  breaks  in  the  skin  surface  must  be 
regarded  as  possible  avenues  for  the  entrance  of  the 
ever-present  pus  micro-organism.  Dirt  may  contain 
these  micro-organisms.  They  may  be  present  on  all 
cutting  instruments  and  they  are  almost  invariably 
present  on  the  hands  and  under  the  nails,  except  just 
after  washing.  All  these  skin  lesions  are  catching  and 
should  be  so  regarded.  Scrupulous  cleanliness,  espe- 
cially when  touching  breaks  in  the  skin  surface,  is  the 
best  prevention.  Such  cleanliness  is  best  obtained  by 
the  vigorous  use  of  soap  and  water.  Alcohol  is  a  good 
disinfectant  for  the  hands,  while  corrosive  sublimate  is 
also  of  some  value.  But  the  main  reliance  must  be 
placed  on  the  mechanical  removal  of  dirt  and  bacteria. 

Tetanus 

Certain  types  of  bacteria  are  particularly  associated 
with  dirt  and  wounds.  One  of  these  micro-organisms 
is  the  bacillus  which  causes  tetanus  or  lockjaw.  This 
disease  has  been  known  for  many  centuries  as  one  that 
occasionally  follows  wounds,  but  it  was  not  until  1884 
that  it  was  discovered  in  animals,  and  in  1885  that  it 
was  reproduced  in  animals.  Not  until  1889  was  the 
bacillus  obtained  in  pure  cultures. 

Tetanus  is  found  everywhere  in  the  Tropics  and  in 
the  Temperate  zones.  The  bacilli  of  tetanus  are  found 
in  the  earth.  They  grow  only  anaerobically  —  that 
is,  only  in  the  absence  of  air.  This  explains  why  tetanus 
is  apt  to  follow  punctured  wounds  like  those  caused  by 
stepping  on  a  rusty  nail.  The  common  sites  of  infec- 
tion in  the  disease  are  the  hands  and  feet.  In  863 


DISEASES  TRANSMITTED  BY  CONTACT    245 

cases  the  gateway  of  infection  was  in  266  cases  in  the 
hands,  and  in  280  cases  in  the  feet. 

Before  the  introduction  of  tetanus  antitoxin  serious 
complications  after  gunshot  wounds  of  the  extremities 
and  in  Fourth  of  July  hand  injuries  were  frequent. 
When  blank  cartridges  were  a  common  feature  of  our 
national  birthday  celebration  there  was  an  annual  toll 
of  several  hundred  deaths  from  tetanus.  In  1903  out 
of  fifty-six  cases  of  so-called  Fourth  of  July  tetanus 
which  were  treated  without  antitoxin  sixteen  died, 
whereas  in  1904  out  of  thirty-three  cases  treated  with 
antitoxin  none  died.  Happily  legislation,  publicity, 
and  tetanus  antitoxin  have  now  almost  entirely  elimi- 
nated the  deaths  from  tetanus  after  the  celebrations 
of  the  Fourth  of  July. 

The  conditions  in  the  European  War  were  favorable 
for  the  prevalence  of  tetanus,  as  the  micro-organisms 
were  in  the  soil  and  punctured  wounds  were  common. 
But  the  use  of  antitoxin  almost  entirely  prevented 
the  disease.  Whenever  soldiers  are  wounded,  they  are 
at  once  given  a  dose  of  antitetanic  serum.  The  general 
opinion  is  that,  unless  the  antitoxin  is  given  before 
the  fixation  of  the  toxins  in  the  nerve  cells  takes  place, 
it  is  of  little,  if  any,  value.  To  be  effective,  therefore, 
it  is  usually  necessary  to  give  antitetanic  serum  as 
soon  as  possible  after  any  deep  wound,  contaminated 
by  dirt,  is  received  and  before  the  disease  develops. 

Rabies 

Rabies  or  hydrophobia  has  been  well  known  for 
centuries.  We  find  the  first  record  in  Aristotle, 
who  wrote,  "  Dogs  suffer  from  madness  that  puts 
them  in  a  state  of  fury,  and  all  animals  which  they 
bite,  when  in  this  condition,  become  also  attacked 
by  madness." 


246  HEALTH  AND  DISEASE 

There  are  also  references  to  this  madness  in  the  works 
of  Virgil,  Horace,  Ovid,  and  Plutarch.  The  presence 
of  the  disease  in  human  beings,  after  dog-bite,  was 
recorded  in  the  first  century  A.D.  Toward  the  end  of 
the  eighteenth  century  the  disease  had  spread  all  over 
Europe  and  was  also  present  in  America.  Rabies 
now  exists  in  almost  every  country  except  in  Den- 
mark, Sweden,  Norway,  England,  and  Switzerland 
where  effective  muzzling  of  dogs  has  stamped  out  the 
disease,  and  in  Australia  where  a  strict  quarantine  of 
six  months  is  enforced  on  dogs.  The  disease  has  been 
constantly  present  in  the  United  States  and  a  con- 
siderable number  of  deaths  occur  from  it  every  year, 
111  in  1908. 

Rabies  is  transferred  by  the  bite  of  a  rabid  animal. 
The  domestic  dog  is  the  usual  animal  to  transfer  the 
disease  to  man,  but  most  of  the  other  animals  are 
subject  to  the  disease.  If  rabies  once  develops  in  the 
system,  the  mortality  is  one  hundred  per  cent.  For- 
tunately not  every  person  bitten  by  a  mad  dog  con- 
tracts rabies.  The  percentage  is,  perhaps,  ten  per  cent. 

Pasteur's  work  on  rabies  has  given  us  an  unusual 
means  of  preventing  the  disease.  Under  his  treat- 
ment the  mortality  from  the  disease  has  been  reduced 
to  a  fraction  of  one  per  cent.  This  discovery  by 
Pasteur  was  one  of  the  most  striking  in  the  history  of 
medicine.  On  the  news  of  his  success  in  treating  rabies 
people  from  all  parts  of  the  world  at  once  went  to  Paris 
for  treatment,  and  now  there  are  Pasteur  Institutes  for 
the  treatment  of  rabies  in  almost  every  country.  Rabies 
is  a  peculiarly  horrible  disease ;  the  symptoms  consist- 
ing of  delirium,  mania,  violent  reflex  spasms  of  the 
mouth  and  larynx  with  inability  to  swallow  make  a 
picture  barely  to  be  imagined.  The  terror  which  the 
words  **  mad  dog  "  arouse  in  the  popular  mind  has  a 
complete  basis  in  fact.  Since  some  months  usually 


elapse  between  the  time  of  the  bite  and  the  onset  of 
the  symptoms,  dread  expectancy  increases  the  terror 
of  this  fatal  disease. 

Curiously  enough,  it  was  not  until  means  were  dis- 
covered for  preventing  and  controlling  the  disease  by 
the  Pasteur  treatment  and  muzzling  and  quarantining 
dogs  that  there  was  any  dispute  concerning  the  ex- 
istence of  rabies.  The  symptoms  and  results  of  mad- 
dog  bites  were  commonplaces  in  the  literature  and  folk 
lore  of  most  peoples.  But  since  the  introduction  of  the 
Pasteur  treatment,  a  body  of  sentimentalists  have  made 
a  vigorous  campaign  against  the  treatment  as  it  ne- 
cessitates the  use  of  animals  to  produce  the  virus. 
These  people  have  carried  their  enthusiasm  to  such 
extremes  as  to  deny  the  existence  of  the  disease. 
People  with  such  oversentimental  minds  have  also 
protested  vigorously  against  the  muzzling  of  dogs  and 
any  effort  to  make  muzzling  effective  always  meets 
with  great  opposition.  As  a  matter  of  fact,  wherever 
the  muzzling  laws  have  been  enforced  effectively,  the 
number  of  cases  of  children  bitten  by  dogs  has  been 
decreased,  together  with  a  marked  decrease  in  the  cases 
of  hydrophobia.  This  was  well  illustrated  by  the 
experiences  in  England.  In  1889  there  were  in  England 
312  cases  of  rabies  and  in  1892  the  number  of  cases  had 
dropped  to  thirty-eight,  —  this  was  under  the  enforce- 
ment of  muzzling  the  dogs.  Then  the  sentimental 
friends  of  the  dogs  succeeded  in  having  the  "  cruel 
muzzle  "  removed.  As  a  result,  in  the  next  five  years, 
fifty-one  people  died  of  the  most  agonizing  death  known 
to  medical  science.  In  1895  there  were  672  cases  of 
rabies.  The  authorities  soon  concluded  that  the  con- 
demnation of  human  beings  to  horrible  death  rather 
outweighed  the  feelings  of  the  dogs  at  having  to  wear 
muzzles,  so  that  the  law  was  strictly  enforced.  As  a 
result  rabies  has  disappeared  from  England  and  is 


248  HEALTH  AND  DISEASE 

kept  out  by  a  strict  quarantine  of  six  months  against 
any  and  all  dogs. 

As  for  the  statement  that  the  Pasteur  treatment 
causes  rather  than  cures  rabies,  the  figures  in  the  de- 
crease of  the  death  rate  should  be  a  sufficient  answer. 
While  other  animals  than  dogs  may  be  bitten  and  be- 
come rabid  and  transmit  the  disease  by  biting,  pre- 
vention of  rabies  is  chiefly  directed  toward  the  dog. 
Adequate  muzzling  laws  and  the  early  application  of 
the  Pasteur  treatment  in  all  persons  bitten  by  a  rabid 
dog  or  a  dog  suspected  of  rabies  will  practically  elim- 
inate the  disease  in  human  beings. 

Hookworm  Disease 

Hookworm  disease  is  of  immense  economic  impor- 
tance in  the  districts  where  it  is  prevalent.  The  anemia 
and  so-called  laziness  which  it  causes  have  been  the 
determining  factor  of  much  of  the  poverty,  mental 
backwardness,  and  disease  which  has  prevented  indus- 
trial and  social  progress  among  the  people  who  are  its 
victims.  In  the  Old  World,  hookworm  disease  was 
probably  known  nearly  3,500  years  ago,  but  the  cause, 
an  intestinal  parasite,  was  not  shown  until  the  middle 
of  the  nineteenth  century.  In  the  United  States  no 
authentic  case  of  the  disease  was  recognized  as  such 
until  1893,  and  between  1893  and  1902  only  thirty-five 
cases  were  diagnosed.  Since  the  latter  date,  however, 
the  hookworm  disease  has  been  understood  more 
accurately  and  it  is  now  recognized  that  some  2,000,000 
people  in  the  United  States,  mostly  in  the  Southern 
States,  suffer  from  this  malady.  The  greatest  number 
of  sufferers  are  between  the  ages  of  five  and  fifteen, 
and  in  some  of  the  southern  schools  thirty  to  eighty 
per  cent  of  the  pupils  are  infected.  In  certain  colleges 
thirty  per  cent  of  the  students  were  found  to  be  infected. 


DISEASES  TRANSMITTED  BY  CONTACT    249 

The  disease  has  an  extensive  range,  for  it  is  found  in  all 
parts  of  the  Tropics  and  belts  the  world  in  a  zone  sixty- 
six  degrees  wide  from  Parallel  36°  North  to  30°  South. 
Practically  all  the  countries  between  these  parallels 
are  infected  with  the  disease. 

Hookworm  disease  in  the  Southern  United  States 
is  due  to  the  so-called  "  New  World  Hookworm",  a 
parasite  which  differs  slightly  from  the  Old  World 
Hookworm.  The  disease  manifests  itself  as  extreme 
lassitude  or  general  inertia. 

When  the  hookworm  disease  was  first  studied  care- 
fully, it  was  found  that  these  tiny  blood-sucking  worms 
were  in  the  intestines  of  the  patients.  The  worms  could 
be  recognized  easily  in  the  stools,  either  as  eggs  or  as 
the  worms  themselves.  It  was  first  believed  that  the 
worm  entered  the  intestinal  tract  through  the  mouth, 
but  it  was  then  found  that  many  of  the  people  who 
suffered  from  the  disease  were  accustomed  to  go  bare- 
foot and  had  a  skin  affliction  called  "ground  itch." 
The  eggs  of  the  worm,  after  discharge  from  the  intes- 
tinal tract  of  an  infected  person,  get  into  the  skin, 
usually  of  the  foot.  The  eggs  then  get  into  the  cir- 
culation and  the  worms  develop  in  the  intestines. 
Probably  ninety  per  cent  of  the  cases  are  due  to  skin 
infection,  and  the  remainder  are  taken  in  through  the 
mouth  by  means  of  contaminated  water  and  food  or 
dirty  fingers.  The  supply  of  shoes  to  the  barefooted 
poor  whites  and  negroes  and  the  introduction  of  the 
sanitary  privy  have  done  much  to  reduce  the  dangers 
of  infection  and  have  markedly  decreased  the  disease. 

The  hookworm  disease  is  a  relatively  easy  thing  to 
control  and  cure.  Drugs,  in  sufficient  doses,  will  kill 
the  worms  and  cure  the  disease.  Education  in  personal 
cleanliness,  the  widespread  introduction  and  use  of  the 
sanitary  privy,  the  wearing  of  shoes,  and  general  sanitary 
measures  are  necessary  to  reduce  the  areas  of  infection. 


CHAPTER  XIV 

THE  VENEREAL  DISEASES  AND  SEX  HYGIENE 

THE  venereal  diseases,  next  to  tuberculosis,  are  the 
most  common  of  the  communicable  diseases  which 
affect  mankind  and  their  danger  to  the  public  health 
and  to  the  race  makes  them  one  of  the  greatest  prob- 
lems of  preventive  medicine.  The  venereal  diseases 
are  included  under  those  transmitted  by  contact 
(usually  but  not  always  by  sexual  contact),  and  are 
three  in  number,  syphilis,  caused  by  the  spirochaeta 
pallida;  gonorrhea,  caused  by  the  gonococcus,  and 
chancroid,  caused  by  the  chancroid  bacillus. 

Syphilis 

The  History  of  Syphilis.  The  history  of  most  diseases 
fades  back  into  the  distant  past,  but  the  history  of 
syphilis  begins  abruptly  in  1494,  two  years  after  the 
discovery  of  America.  Syphilitic  bones,  presumably, 
but  not  positively,  of  the  pre-Columbian  age  in  America, 
and  Spanish  documents  indicate  that  syphilis  was  in- 
troduced into  Europe  from  Haiti  by  the  sailors  of 
Columbus.  In  1494  the  army  of  mercenaries  collected 
by  Charles  VIII,  of  France,  invaded  Italy.  With  this 
invasion  syphilis  appeared.  As  the  soldiers  scattered, 
syphilis  swept  over  Europe  in  a  rapidly  increasing 
epidemic,  and,  before  the  year  1500,  syphilis  had  in- 
vaded all  of  Europe  and  had  appeared  in  India. 

The  first  epidemic  was  of  extraordinary  severity,  a 

250 


VENEREAL  DISEASES,  SEX  HYGIENE    251 

severity  which  is  essentially  a  characteristic  of  the 
introduction  of  a  new  disease.  In  this  first  epidemic 
syphilis  frequently  ran  an  acute  fatal  course,  as  is 
evidenced  by  the  drastic  measures  taken  against  it. 
Aberdeen,  Scotland,  and  Paris  passed  stringent  laws 
banishing  all  those  afflicted  with  this  new  plague. 
Within  the  next  hundred  years,  however,  syphilis  took 
on  the  essential  characteristics  which  we  recognize 
to-day.  On  account  of  the  prevalence  of  syphilis 
throughout  the  world,  a  vast  literature  concerning  the 
disease  grew  up,  and  the  clinical  facts  concerning  it 
became  well  known.  But  only  since  1905,  the  date  of 
the  discovery,  by  Schaudinn  and  Hoffmann,  of  the 
causative  agent  of  syphilis,  the  spirochseta  pallida, 
have  we  acquired  the  mass  of  exact  information  con- 
cerning syphilis  and  its  treatment  such  as  we  possess 
in  the  case  of  no  other  disease. 

Syphilis  is  a  disease  peculiar  to  man  and  is  acquired 
in  from  ninety  to  ninety-five  per  cent  of  the  cases 
through  sexual  contact.  Infection  with  syphilis  re- 
quires a  break  in  the  skin,  although  this  break  may  be 
microscopic.  The  so-called  initial  lesion,  or  chancre, 
appears  where  the  infection  is  actually  received. 

The  Course  of  Syphilis.  The  chancre  (initial  lesion 
or  primary  sore)  appears  slowly  and  usually  painlessly 
after  an  incubation  period  of  about  six  weeks.  The 
chancre,  since  the  disease  is  usually  acquired  by  sexual 
contact,  is  usually  on  the  sexual  organs.  Next  in 
order  of  appearance,  some  weeks  later,  is  a  rash.  This 
coincides  with  the  general  invasion  of  the  body  with 
the  spirochsetae.  There  may  also  be  sores  in  the 
mouth,  enlarged  glands,  and  fever.  This  stage,  when 
uninfluenced  by  treatment,  may  last  for  weeks  and 
months.  This  so-called  secondary  stage  may  or  may 
not  be  followed  by  localized  inflammatory  lesions  which 
are  called  gummata.  The  so-called  tertiary  stage 


252  HEALTH  AND  DISEASE 

merges  into  the  stage  of  the  end  results  of  syphilis,  — 
arterio-sclerosis,  aneurysm,  tabes  (locomotor  ataxia), 
and  general  paresis.  Usually  the  chancre,  particularly 
in  men,  can  be  detected,  but  any  or  all  of  the  other 
stages  of  the  disease  may  not  be  apparent  in  an  in- 
dividual case.  Then,  too,  the  signs  of  syphilis,  active 
and  infectious,  may  be  evident  to  the  physician,  but 
unsuspected  by  the  victim.  This  is  especially  true  of 
women,  who  may  be  entirely  ignorant  of  the  fact  that 
they  have  the  disease.  It  is  generally  conceded,  but  not 
positively  proven,  that  one  attack  of  syphilis  prevents 
reinfection.  Reported  instances  of  reinfection  are  to 
be  explained  as  recrudescences  of  the  original  infection. 

The  Dangerous  Lesions  of  Syphilis.  All  the  lesions 
of  syphilis,  even  aneurysm  and  locomotor  ataxia  which 
often  appear  years  after  the  infection,  are  caused  by 
the  actual  invasion  of  the  tissues  by  the  spirochsetae. 
But  syphilis  is  transmissible  only  when  a  syphilitic 
lesion  comes  into  direct  or  indirect  contact  with  an- 
other person.  If  the  spirochsetse  are  confined  to  the 
brain,  for  example,  they  cannot  transmit  the  disease. 
Hence  the  primary  and  secondary  lesions  are  practi- 
cally the  only  infectious  lesions.  In  the  secondary 
stage,  in  which  spirochseta-containing  lesions  are 
present  on  the  skin  and  on  all  the  mucous  membranes, 
syphilis  is  particularly  dangerous.  This  is  the  stage  in 
which  doctors,  nurses,  innocent  members  of  the  family, 
and  friends  are  most  liable  to  be  infected  while  per- 
forming their  professional  duties  or  by  the  use  of  com- 
mon utensils. 

From  ninety  to  ninety-five  per  cent  of  the  cases  of 
syphilis  in  adults  are  acquired  through  sexual  inter- 
course. This  includes  the  infection  of  the  innocent 
partner  in  the  legitimate  relations  of  marriage  as  well 
as  infection  in  illicit  intercourse.  The  great  source  of 
syphilis  is,  of  course,  illicit  sexual  intercourse.  The 


VENEREAL  DISEASES,  SEX  HYGIENE    253 

female  partners  of  such  irregular  relations  may  be  either 
frank  or  clandestine  prostitutes.  Statistics  show  that 
from  eighty  to  eighty-five  per  cent  of  prostitutes  con- 
tract syphilis  during  their  career  and  usually  fairly 
early.  This  means  that  practically  all  prostitutes  are 
syphilitic,  but  that  they  are  not  necessarily  in  the 
stage  of  the  disease  in  which  the  infection  is  trans- 
missible. It  has  become  fashionable  to  say  that  syphilis 
in  one-half  the  cases  is  acquired  innocently.  In  such  a 
statement  innocent  syphilis  includes  all  congenital 
syphilis,  all  extra-genital  chancres,  even  when  acquired 
during  illicit  intercourse,  and  one-half  of  the  double 
infections  of  the  legal  partners.  Such  general  state- 
ments as  to  innocent  syphilis  require  qualification  in 
order  not  to  alarm  unnecessarily  the  public  concerning 
the  dangers  of  acquiring  syphilis  in  other  ways  than  by 
sexual  intercourse. 

Transmission  of  Syphilis  by  Indirect  Contact.  The 
spirochaeta  is  of  very  short  life  (a  few  hours  at  the 
most)  outside  the  body,  and  furthermore  the  spirochse- 
tse  are  easily  destroyed  by  any  of  the  common  antisep- 
tics. Transmission  of  syphilis  by  the  common  use  of 
pipes,  drinking  cups,  and  utensils  is  not  uncommon, 
but  transmission  in  food  or  by  waiters,  an  example  of 
common  belief  concerning  the  disease,  is  almost  un- 
known. In  general,  the  indirect  transmission  of  syph- 
ilis is  excessively  rare,  except  among  people  with 
extraordinarily  uncleanly  habits.  The  penalty  of 
contracting  syphilis  is  so  great,  however,  that  all 
reasonable  precautions  should  be  taken.  But  persons 
of  clean  personal  habits  need  have  little  fear  of  contract- 
ing syphilis  indirectly.  The  transmission  of  syphilis 
is  direct,  but  in  five  to  ten  per  cent  of  the  cases  the 
direct  contact  is  not  sexual  intercourse. 

The  extra-genital  chancres,  which  appear  when  syph- 
ilis is  contracted  in  contact  other  than  sexual  inter- 


254  HEALTH  AND  DISEASE 

course,  may  occur  anywhere  on  the  body,  but  they  are 
most  frequent  on  the  hands,  face,  or  mouth.  The 
moist  lesions  of  the  mouths  of  syphilitics  are  the  most 
usual  source  of  the  infection.  Kissing  is,  perhaps,  the 
common  way  in  which  the  infection  is  thus  transferred. 
Then,  too,  doctors  and  nurses  not  infrequently  contract 
syphilis  on  the  fingers  or  hand  in  the  course  of  their 
professional  duties. 

Hereditary  or  Congenital  Syphilis.  Hereditary  syph- 
ilis means  that  the  syphilis  of  the  child  was  trans- 
mitted by  the  mother  in  the  uterus.  The  mother  must 
be  syphilitic,  the  father  not  necessarily  so.  A  healthy 
child  of  a  syphilitic  mother  may  contract  syphilis 
directly  after  birth.  Hereditary  syphilis  has  all  the 
characteristics  of  adult  syphilis,  but,  in  general,  the 
involvement  of  the  organs  is  much  greater  and  the 
disturbance  of  health  is  more  severe.  Not  infre- 
quently the  foetus  dies  and  miscarriage  occurs.  Syph- 
ilis is  one  of  the  great  causes  of  spontaneous  mis- 
carriages. The  child  may  be  born  with  the  active 
disease  and,  in  such  an  event,  usually  dies.  But  the 
disease  may  only  manifest  itself  later  in  life,  though 
nearly  always  before  the  age  of  puberty.  Congenital 
syphilis  may  cause  retarded  development  of  the  body, 
and  infantilism,  or  again  damage  to  the  nervous  system, 
including  idiocy.  Characteristic  deformities  of  the 
bones  and  teeth  are  common  in  congenital  syphilis, 
and  the  eyes  and  ears  are  frequently  affected.  Deaf- 
mutism  may  be  of  syphilitic  origin.  Despite  the  popu- 
lar belief,  there  is  no  evidence  of  the  transmission  of 
syphilis  to  the  third  and  fourth  generations. 

Frequency  of  Syphilis.  Syphilis  affects  all  classes 
of  society.  From  the  nature  of  the  disease  it  is  im- 
possible to  ascertain  with  any  degree  of  accuracy  the 
prevalence  of  this  infection.  The  estimates  of  the  best 
authorities  show  that  about  five  per  cent  of  the  adult 


VENEREAL  DISEASES,  SEX  HYGIENE    255 

males  in  the  United  States  acquire  syphilis  and  that 
the  percentage  is  probably  higher  in  Europe.  There 
are  probably  five  male  syphilitics  to  one  female.  There 
is  ground  for  the  belief  that  syphilis  is  not  on  the  in- 
crease. , 

The  Effects  of  Syphilis.  Except  in  the  hereditary 
form,  syphilis  in  its  active  stage  rarely  causes  death. 
Few  syphilitics  are  even  compelled,  during  the  active 
stage  of  the  disease,  to  give  up  business  or  to  suffer 
much  inconvenience.  It  is  the  late  effects  of  syphilis 
which  interfere  with  life  and  health.  These  late  effects 
may  manifest  themselves  within  a  few  months  or  only 
after  twenty  or  even  forty  years.  We  have  also  learned 
through  experience  to  associate  certain  general  condi- 
tions with  syphilis,  as  it  seems  to  be  an  important 
factor  in  many  cases  of  premature  old  age,  early  arterio- 
sclerosis, and  general  organic  degeneration.  It  is  im- 
possible to  estimate  with  any  degree  of  accuracy  the 
prevalence  of  these  late  results.  Many  of  these  lesions 
have  only  recently  been  discovered  to  be  syphilitic. 
Again,  the  efficiency  of  treatment  does  much  to  reduce 
the  frequency  of  the  late  complications  and  only  re- 
cently have  we  had  the  knowledge  and  the  means  for 
thorough  treatment. 

Syphilis  is  particularly  prone  to  affect  the  nervous 
system.  Older  statistics  gave  this  frequency  as  one 
to  three,  but  the  majority  of  these  were,  perhaps,  reme- 
diable, in  the  light  of  our  present  knowledge.  The 
statistics  of  the  future  will  undoubtedly  show  a  much 
lower  incidence.  Nearly  ten  per  cent  of  all  admissions 
to  hospitals  for  the  insane  have  an  incurable  brain 
disease  due  to  syphilis  —  general  paralysis  of  the  insane, 
or  general  paresis.  This  comes  on  usually  from  six  to 
ten  years  after  infection.  More  persons  in  New  York 
City  die  of  general  paralysis  than  of  typhoid  fever. 
Out  of  a  group  of  female  prostitutes  1.3  per  cent 


256  HEALTH  AND  DISEASE 

developed  this  incurable  brain  disease  and  4.7  per  cent 
of  a  group  of  male  syphilitics.  Patients  with  general 
paresis  often  live  for  years.  They  may  be  entirely 
harmless  and  may  not  require  confinement,  but  enor- 
mous numbers  of  them  have  to  be  restrained  at  public 
expense  in  public  institutions  for  the  protection  of  the 
community.  Consequently,  syphilis  must  be  regarded 
in  part  as  an  economic  problem  as  well  as  a  medical 
and  social  problem. 

Tabes  (locomotor  ataxia)  is,  in  all  its  modifications,  a 
relatively  common  disease  and  the  end  result  of  syph- 
ilis. Tabes  frequently  causes  industrial  incapacity, 
and  we  find  many  tabetics  in  almshouses  and  the  com- 
munity hospitals  for  chronic  disease.  Here,  again,  we 
see  the  economic  aspect  of  the  problem. 

Syphilis  is  a  frequent  cause  of  heart  disease,  of  arterio- 
sclerosis, and  of  aneurysm.  The  ravages  of  syphilis 
do  not  spare  any  tissue  of  the  body,  but  we  see  its 
most  disastrous,  as  well  as  its  most  common,  effects 
on  the  nervous  system  and  the  cardiovascular  system. 

Carefully  tabulated  life  insurance  statistics  show 
that  the  acquisition  of  syphilis  generally  shortens  life 
about  five  and  a  half  years.  Many  syphilitics,  of 
course,  indulge  in  other  excesses  which  tend  to  shorten 
life.  Probably  a  goodly  proportion  of  syphilitics,  who 
secure  early  and  efficient  treatment  and  who  lead  whole- 
some lives,  live  out  their  allotted  years. 

The  Treatment  and  Cure  of  Syphilis.  Despite  the 
popular  pessimism  in  regard  to  the  cure  of  syphilis,  it 
is  now  essentially  a  curable  disease.  Experience 
shows  that  even  without  treatment  syphilitics  appar- 
ently occasionally  recover  completely.  With  treat- 
ment the  proportion  of  recoveries  is  much  higher, 
for  we  are  peculiarly  fortunate  in  possessing  a  va- 
riety of  agents  which  facilitate  effective  treatment 
of  syphilis. 


VENEREAL  DISEASES,  SEX  HYGIENE    257 

In  the  first  place,  since  1905  we  have  known  the 
causative  agent  of  syphilis,  an  organism  which  is 
present  and  demonstrable  in  syphilitic  lesions.  Where- 
as formerly  it  was  often  necessary  to  await  the  develop- 
ment of  the  typical  secondary  stage  after  the  appear- 
ance of  the  chancre,  now  the  diagnosis  can  be  made  in 
the  beginning.  In  favorable  cases  prompt  treatment 
probably  aborts  the  disease.  It  is  axiomatic  that 
early  diagnosis  is  essential,  not  only  for  the  treatment 
and  cure,  but  also  for  the  control  of  its  future  dissemina- 
tion. 

Secondly,  since  1906-07  we  have  had  a  reliable  blood 
test,  known  as  the  Wassermann  reaction.  This  com- 
plicated and  only  partially  understood  test  was  first 
described  by  Wassermann,  Neisser,  and  Bruck.  For 
the  requirements  of  the  test  a  small  amount  of  blood, 
usually  from  the  arm  vein,  is  taken  from  the  patient. 
The  reaction  involves  the  interaction  of  substances  of 
this  blood  with  the  blood  of  a  guinea  pig,  the  blood  of  a 
specially  treated  rabbit,  sheep's  blood  corpuscles,  and 
a  chemical  substence  sometimes,  but  not  necessarily, 
derived  from  syphilitic  tissue.  This  complex  reaction 
has  been  of  tremendous  assistance.  It  is  not  present 
in  the  primary  stage  when  the  disease  is  local  and  when 
the  disease  may  be  recognized  by  finding  spirochsetse, 
but  it  is  almost  universally  present  in  the  active  stages 
of  syphilis,  and  usually  present  even  when  the  syphilis 
is  latent.  By  means  of  this  reaction  the  probability 
of  the  persistence  of  internal  syphilis  can  be  established 
even  in  the  absence  of  external  signs.  It  has  also 
enabled  the  classification  of  obscure  manifestations  as 
syphilitic.  But  of  greater  importance  is  its  relation  to 
treatment.  While  even  the  most  energetic  treatment 
may  not  bring  about  a  negative  reaction,  and  treat- 
ment may  be  necessary  in  the  face  of  a  negative  re- 
action, yet,  roughly,  intelligent  treatment  is  only 


258  HEALTH  AND  DISEASE 

possible  when  controlled  by  this  reaction.  Other 
tests  of  less,  but  of  distinct,  value  are  applicable  to  the 
examination  of  the  spinal  fluid  for  syphilis  of  the 
nervous  system. 

Therapeutic  Agents.  Potassium  iodide  and  mer- 
cury have  long  been  known  to  be  of  value  in  the  treat- 
ment of  syphilis,  mercury,  in  particular,  being  of  the 
greatest  value.  But  both  fade  into  comparative 
insignificance  beside  Ehrlich's  great  discovery,  in 
1909,  of  arseno-benzol  or  Salvarsan.  This  arsenical 
compound  is  usually  called  **  606  ",  since  that  was  the 
606th  drug  tested  in  the  series  of  experiments.  This 
research  by  Ehrlich  deserves  special  mention  since  he 
deliberately  set  to  work  to  find  a  combination  of 
arsenic  which  would  destroy  parasitic  substances  in 
the  blood  and  yet  be  harmless  to  the  human  organs. 
Arseno-benzol  represents  the  beginning  of  chemo- 
therapy. While  subsequent  experience  has  not  con- 
firmed the  earlier  hope  of  a  complete  cure  by  a  single 
dose,  yet  the  administration  of  arseno-benzol  in  re- 
peated doses  and  in  conjunction  with  mercury,  when 
controlled  by  the  Wassermann  reaction,  is  remarkably 
effective  in  the  cure  of  syphilis. 

It  is  evident  that  no  drug  can  replace  destroyed 
tissue  and  experience  shows  that  general  paresis  cannot 
be  cured.  The  later  the  stage  in  which  treatment  is 
begun,  the  less  favorable  the  chances  for  complete 
cure.  In  the  early  stage,  when  the  disease  is  largely 
local,  complete  cure  is  nearly  certain.  In  the  secondary 
stage,  failure  to  cure  ought  to  be  very  small,  about 
one  per  cent.  It  is  probably  impossible  to  guarantee 
a  cure,  for,  despite  all  treatment,  an  unknown  small 
percentage  will  develop  organic  brain  and  arterial 
disease.  The  importance  of  early  diagnosis  cannot 
be  overemphasized.  It  is  unfortunate  that  many 
syphilitics,  conscience  stricken  by  this  manifestation 


VENEREAL  DISEASES,  SEX  HYGIENE    259 

of  irregular  living,  decide  to  obtain  inadequate  treat- 
ment from  such  incompetent  sources  as  newspapers, 
quacks,  and  the  corner  drug  store.  In  point  of  fact 
their  family  physician  is  too  conversant  with  the  irreg- 
ularities of  human  conduct  and  the  prevalence  of 
syphilis  in  all  walks  of  life  and  too  appreciative  of  the 
importance  of  energetic  treatment  to  bother  overmuch 
with  moralizing  reproaches.  In  not  securing,  at  the 
first  appearance  of  any  suspicious  lesion  of  syphilis, 
the  most  competent  advice,  the  individual  may  lose 
the  benefit  of  the  probable  certainty  of  cure.  In 
addition  it  is  not  uncommon,  unfortunately,  for  the 
unwise  confession  of  syphilis  to  lead  to  blackmail. 

From  the  point  of  view  of  the  community  and  for 
the  prevention  of  the  spread  of  syphilis,  early  diagnosis 
and  energetic  treatment  are  of  the  utmost  importance. 
Ordinarily  the  dangerous  infective  stage  of  syphilis 
persists  for  months,  but  by  means  of  intensive  treat- 
ment the  infectious  period  can  be  shortened  to  as  many 
weeks  or  less.  This  means  the  elimination  of  many 
cases.  It  necessitates,  however,  in  many  instances 
free  examination  and  free  treatment.  Largely  on 
moral  grounds  such  examinations  and  such  treatment 
are  not  now  readily  available.  The  justification  of  such 
expenditures  of  private  and  public  money  can  be  made, 
however,  not  only  in  the  increased  protection  of  the 
community  against  disease,  but  also  in  the  actual 
saving  of  money  which  will  eventually  result  in  the 
prevention  of  a  large  proportion  of  organic  diseases 
of  the  arteries  and  of  the  brain  of  syphilitic  origin. 
The  victims  of  these  diseases  must  eventually  be  cared 
for  by  public  money  in  hospitals,  almshouses,  and 
insane  asylums. 

Syphilis  and  Marriage.  The  problem  of  the  mar- 
riage of  a  syphilitic  was  formerly  exceedingly  compli- 
cated. Syphilis  occurs  most  frequently  in  early  adult 


260  HEALTH  AND  DISEASE 

life,  approximately  at  or  just  before  the  usual  age  of 
marriage,  so  that  this  is  a  question  which  is  constantly 
present.  The  recent  discoveries  concerning  syphilis, 
however,  enable  this  question  to  be  answered  very 
definitely  in  the  individual  case  and  reasonably  defi- 
nitely in  the  abstract. 

The  dangers  of  the  marriage  of  syphilitics  are  three : 
(1)  the  infection  of  the  partner;  (2)  the  propagation 
of  syphilis  to  the  children,  and  (3)  the  assumption  of 
family  burdens  when  that  is  not  justified  on  account  of 
impending  disability  of  the  syphilitic.  The  third 
point  has  been  discussed  already.  The  first  two  in- 
volve practically  identical  considerations,  since  the 
problem  usually  concerns  males,  and  we  know  from 
studies  of  the  Wassermann  reaction  that  syphilis  in 
the  child  necessitates  syphilis  in  the  mother.  A 
reasonable  rule  is  that  a  syphilitic  may  marry  five 
years  after  infection,  provided  that  he  has  been  thor- 
oughly treated  during  the  first  three  years  and  has 
shown  no  manifestation  of  the  disease  during  the  last 
two  years.  And  this  rule  holds  despite  the  fact  that 
he  may  have  a  positive  Wassermann  reaction.  Under 
such  conditions  the  former  syphilitic  will  not  infect 
his  wife  and  he  will  propagate  normal  children.  Syph- 
ilis, therefore,  cannot  be  considered  to  be  a  permanent 
bar  to  matrimony,  for  experience  has  demonstrated 
the  safety  of  such  a  rule  of  conduct. 

Gonorrhea 

The  second  of  the  venereal  diseases  is  gonorrhea, 
caused  by  the  specific  micro-organism,  the  gonococcus. 
Gonorrhea  is  generally  regarded  as  a  local  disease  of 
the  genital  organs,  but,  while  it  may  remain  a  local 
disease,  its  possible  effects  entitle  it  to  much  more 
serious  consideration  than  it  has  received  hitherto. 


VENEREAL  DISEASES,  SEX  HYGIENE    261 

There  are  no  statistics  to  show  the  prevalence  of 
gonorrhea,  but  it  is  agreed  that  probably  a  majority 
of  men  suffer  from  it  at  some  time  in  their  lives.  The 
disease  is  much  less  common  in  women.  Since  one 
attack  of  gonorrhea  does  not  prevent  a  second  attack, 
many  individuals  suffer  repeated  attacks.  Like  syph- 
ilis, gonorrhea  is  most  common  in  early  adult  life  and 
is  inseparably  connected  with  loose  living. 

In  over  ninety-five  per  cent  of  the  cases  gonorrhea 
is  transferred  by  sexual  intercourse.  The  exceptions 
are  mainly  two :  (1)  Gonorrheal  conjunctivitis  of  the 
new-born,  which  the  infant  receives  from  the  mother 
and  which  is  a  common  cause  of  blindness;  and  (2) 
gonorrheal  vaginitis  in  young  girls,  which  occurs  fre- 
quently in  epidemics  in  institutions.  The  infection 
in  young  girls  is  transferred  by  the  use  of  common 
utensils,  like  towels,  and  the  general  careless  habits  of 
childhood.  Among  adults  gonorrhea  is  extremely 
rarely  contracted  in  any  other  way  than  by  sexual 
intercourse.  The  somewhat  common  belief  to  the  con- 
trary is  founded  on  and  fostered  by  the  natural  reluc- 
tance to  confess  to  irregular  living. 

The  clinical  symptoms  of  gonorrhea  usually  appear 
from  four  to  seven  days  after  exposure.  There  is  a 
strong  tendency  to  spontaneous  recovery,  so  that 
we  have  many  so-called  cures  and  many  so-called 
"  specialists  in  diseases  of  men."  Among  the  laity 
the  disease  is  lightly  regarded  as  a  trivial  occurrence 
and  is  often  compared  to  a  **  hard  cold."  Consequently 
little  attention  is  too  often  paid  to  the  disease.  But 
the  disease  may  become  general  and  the  patient  die 
of  gonorrheal  sepsis.  Gonorrheal  rheumatism  is  not 
infrequent  and  this  condition  may  be  persistent  and, 
in  the  end,  crippling.  Rarely,  gonorrhea  may  be  the 
cause  of  valvular  disease  of  the  heart.  In  men  the 
infection  may  extend  and  lock  off  the  outlet  of  the 


262  HEALTH  AND  DISEASE 

testicular  secretion.  This  does  not  interfere  with  sex- 
ual potency,  but  it  does  cause  sterility.  Sterility  is 
commonly  attributed  to  some  abnormality  in  women, 
but  twenty  per  cent  of  the  cases  may  be  traced  to  the 
effects  of  an  old  gonorrhea  in  the  male.  Stricture  and 
the  attendant  complications  also  follow  gonorrhea  in 
the  male. 

The  anatomy  of  the  female  favors  the  existence  of 
the  gonorrheal  inflammation  in  the  pelvic  organs. 
Gonorrhea  is  probably  the  most  frequent  cause  of  in- 
flammatory disease  of  the  pelvic  organs  of  women, 
which  not  infrequently  cause  mutilating  operations 
involving  the  removal  of  organs.  Sterility  and  chronic 
invalidism,  even  death,  may  be  the  end  result.  The 
disease  is  frequently  hard  to  diagnose  in  women  and, 
unlike  the  case  with  men,  it  may  be  unsuspected  by 
the  victim. 

As  long  as  an  individual  has  gonorrhea,  he  or  she 
may  transmit  the  disease  by  sexual  intercourse.  Cure 
is  usually  achieved  in  men  in  the  course  of  a  few  weeks, 
but  it  may  be  postponed  for  a  long  time.  Attacks, 
after  the  first,  are  particularly  persistent  and  chronic 
gonorrhea  is  notoriously  obstinate.  The  cessation  or 
diminution  of  the  discharge  is  not  proof  of  cure  nor  is 
the  lapse  of  any  given  period  of  time.  In  women  the 
course  of  the  disease  is  more  variable.  Cure  should 
always  be  established  by  competent  medical  advice, 
and  it  goes  without  saying  that  marriage  is  only  per- 
missible after  positive  cure.  The  failure  to  respect 
this  rule  of  decency  and  commonsense  may  result  in 
an  invalid  wife,  a  childless  wife,  or  a  blind  child. 

Chancroid 

Chancroid,  the  third  venereal  disease,  is  due  to  a 
specific  bacillus  and  causes  superficial  ulcers.  The 


VENEREAL  DISEASES,  SEX  HYGIENE    263 

disease  is  almost  entirely  local  and  it  is  transmitted  in 
almost  every  case  by  the  direct  contact  of  sexual  inter- 
course. In  general,  a  much  milder  disease  than  syph- 
ilis or  gonorrhea,  the  existence  of  chancroid  depends  on 
the  same  factors  which  obtain  in  the  other  venereal 
diseases.  One  attack  does  not  prevent  subsequent 
reinfection. 

Sex  Hygiene 

Nature  has  taken  care  that  the  human  race  shall 
continue  by  implanting  in  each  individual  the  instinct 
of  sex  to  which,  at  some  time  or  other,  he  will  respond. 
The  instinct  of  self-preservation  is  the  only  one  which  is 
more  strongly  a  part  of  human  nature,  and  it  is  a  ques- 
tion whether  the  desire  for  existence  is  not,  in  a  sense, 
secondary,  in  that  it  enables  the  individual  to  live  and 
propagate  his  kind.  But  the  presence  of  this  powerful 
sex  instinct  does  not  necessarily  mean  that  it  must  be 
gratified.  Experience  demonstrates  conclusively  that, 
contrary  to  the  teachings  of  the  licentious,  sexual  con- 
tinence is  detrimental  neither  to  mind  nor  body. 

The  fulfillment  of  the  sexual  act  was  intended  for  the 
purpose  of  propagation,  and  our  social  structure  depends 
for  its  protection  on  the  restrictions  of  sexual  inter- 
course to  family  life.  General  unrestricted  sexual 
intercourse  would  completely  revolutionize  the  founda- 
tions of  life  —  foundations  on  which  depend  the  pur- 
poses of  Nature.  As  a  result  it  is  necessary  to  regard 
irregular  living,  in  part  at  least,  from  the  so-called 
moral  viewpoint. 

For  the  normal  man  or  woman  with  the  normal 
sexual  appetite  it  is,  perhaps,  more  convincing  to  look 
at  the  sexual  problem  from  the  viewpoint  of  health, 
not  only  the  health  of  the  individual,  but  also  the  health 
of  the  partner  in  the  marital  relation  and  of  posterity. 
First  and  foremost  of  these  considerations  is  the  fact 


264  HEALTH  AND  DISEASE 

that  gratification  of  the  sexual  appetite  outside  of 
wedlock  involves  exposure  to  venereal  disease.  One 
can  safely  generalize  by  saying  that  the  man  or  woman 
who  breaks  through  social  conventions  by  illicit  inter- 
course for  one  partner,  will  break  through  for  another 
partner.  Such  a  generalization,  often  indignantly 
denied,  especially  for  the  duration  of  a  particular 
'*  affair  ",  is  frequently  proven  true  by  the  man  by  the 
contraction  of  disease  as  well  as  by  his  own  promis- 
cuous conduct.  Illicit  intercourse  leads  almost  inevi- 
tably to  promiscuous  intercourse  and  that  means 
exposure  to  venereal  disease.  Exposure,  however,  does 
not  necessarily  mean  disease,  although  most  prosti- 
tutes contract  syphilis  and  practically  all  gonorrhea. 
Infection,  then,  is  a  matter  of  chance. 

A  social  order  where  sexual  irregularities  exist,  but 
which  are  not  recognized  as  fundamentally  opposed 
to  the  order  itself,  has  attempted  to  solve  the  problem 
of  venereal  disease  by  several  prophylactic  measures. 
The  first  attempt  at  prevention  of  the  contraction  of 
venereal  disease  is  the  regulation  of  prostitution,  with 
a  periodic  medical  examination  of  the  prostitutes. 
Experience  has  shown  that  it  is  impossible  thoroughly 
to  carry  out  such  regulation.  The  licensed  public 
prostitute  is  so  much  of  an  outcast  that  clandestine 
prostitution  is  much  increased  by  any  such  system. 
Women  will  only  become  licensed  when  they  feel  that 
they  can  no  longer  attract  men  by  their  personal  charms 
and  that  the  only  remaining  way  of  livelihood  is  through 
public  announcement  of  their  occupation.  Again,  the 
licensed  prostitute  may  easily  develop  and  spread 
diseases  in  the  interim  between  examinations.  On  the 
whole,  while  licensed  prostitution  has  its  advocates, 
it  must  be  admitted  that  licensed  prostitution  in  any 
community  has  not  appreciably  lessened  disease.  Such 
a  system  gives  a  false  sense  of  security  to  the  offender 


VENEREAL  DISEASES,  SEX  HYGIENE    265 

and  encourages  the  development  of  illicit  sexual  habits 
which  will  inevitably  bring  disease. 

Various  methods  of  medical  prophylaxis  have  been 
suggested  to  prevent  disease  in  the  male,  and  their 
use  has  been  carefully  studied  in  the  navy.  Without 
question  the  use  of  medical  prophylactics  has  markedly 
reduced  venereal  disease,  always  a  large  problem  in 
navies  the  world  over.  Yet  conditions  obtain  in  the 
navy  which  make  the  use  of  the  prophylactic  unusually 
effective.  After  exposure,  within  a  few  hours,  the  use 
of  such  measures  is  made  obligatory.  It  has  been 
amply  demonstrated  that  calomel  ointment,  properly 
used,  is  a  reasonably  certain  protection  from  syphilis, 
while  the  silver  salts  have  a  similar  protective  power 
against  gonorrhea.  But  what  the  final  attitude  will 
be  concerning  the  use  of  prophylactics  against  venereal 
disease  is  not  clear,  and  this  aside  from  any  questions 
of  morality.  It  is  certain  that  under  the  special  condi- 
tions of  the  navy,  a  considerable  amount  of  disease  is 
prevented  for  the  time  being.  Prophylactic  measures 
on  a  wide  scale,  however,  cannot  be  accounted  of  real 
value  even  in  the  prevention  of  venereal  disease,  for 
the  conditions  of  the  prompt  thorough  use  of  such 
prophylactics  are  not  easily  obtainable  or  carried  out. 
It  is  at  least  open  to  question  whether  general  knowl- 
edge and  use  of  prophylactics  would  actually  decrease 
the  mass  of  venereal  disease.  The  disease  actually 
prevented  would  in  part  be  compensated  for  by  addi- 
tional disease  acquired  through  an  increase  in  irregular 
living  inevitably  favored  by  the  sense  of  security  from 
venereal  disease,  however  false  or  difficult  of  attain- 
ment that  security  may  be. 

The  Worry  and  Strain  of  Illicit  Sex  Indulgence. 
Venereal  disease  is  not  the  only  penalty  of  irregular 
living  that  is  paid  in  terms  of  damage  to  the  human 
system.  The  illegitimate  child,  the  abortion  —  a 


266  HEALTH  AND  DISEASE 

crime  in  law  —  with  its  dangers  to  life  and  health,  the 
fear  of  pregnancy,  the  fear  of  exposure,  bring  the  burden 
of  worry  mostly  to  the  female  partner,  but  the  male 
carries  his  share.  The  man  may  pay  the  penalty  of 
his  so-called  indiscretions  in  the  publicity  of  the  court 
room.  Newspapers  are  filled  with  disclosures  of  pri- 
vate lives,  but  in  reality  very  few  get  into  print.  As 
the  general  standards  of  morality  have  been  raised 
step  by  step,  the  greater  is  the  possibility  of  the  man 
and  woman  of  irregular  lives  being  brought  face  to 
face  with  a  dilemma  of  their  own  making,  public  dis- 
closures and  the  results,  or  a  life  of  secret  worry. 
Worry  acts  deviously  and  insidiously.  None  are 
immune,  although  all  are  variably  affected.  The  end 
results  of  worry  are  indirectly  brought  about,  but 
they  are  none  the  less  frequently  serious.  Irregular 
living  inevitably  means  worry,  and  worry  may  be  the 
determining  factor  not  only  for  health  but  for  actual 
material  success  in  life.  And  this  is  quite  apart  from 
the  effect  of  irregular  living  and  the  breaking  of  moral 
as  well  as  legal  laws  upon  the  mental  and  moral  fiber 
and  tone  of  the  individual. 

Sex  Habits.  Irregular  living  with  its  attendant  evils 
of  venereal  disease  and  worry  may  rightly  be  attributed 
to  faulty  sex  habits.  Habits  of  sex  are  formed  as  are 
other  habits.  There  is  the  habit  of  continence  as  well 
as  the  habit  of  sexual  indulgence.  Illicit  sexual  indul- 
gence, when  persisted  in,  almost  invariably  leads  to 
promiscuity.  The  man  who  thinks  himself  secure  from 
venereal  disease  and  worry  in  his  intercourse  with  one 
partner  is  establishing  a  habit  which  will  call  for  grati- 
fication when  he  is  tired  of  his  early  partner  or  she  is 
removed  by  circumstances.  Then,  too,  the  habit  of 
sex  gratification,  once  established,  usually  makes 
serious  inroads  on  time  and  energy.  Even  business, 
or  at  least  serious  business,  is  subordinated  to  this 


VENEREAL  DISEASES,  SEX  HYGIENE    267 

habit.  The  life  and  mind  of  such  a  person  are  on  a 
sexual  plane.  Furthermore,  the  habit  of  sex  grati- 
fication has  evil  attendants.  The  relation  of  alcohol 
to  loose  living  is  intimate.  Alcoholic  excess  is  often 
necessary  to  remove  the  restraint  of  reason  from  the 
sexual  appetite,  and  it  happens  that  some  people,  on 
this  account,  wilfully  indulge  in  alcoholic  excess. 

While  society  has  decreed  sexual  restraint  on  moral 
grounds,  we  find  ample  justification  for  such  restraint 
on  the  grounds  of  health.  Prophylaxis  does  not  solve 
the  problem  of  sex  hygiene  and,  as  a  matter  of  fact,  at 
least  thus  far,  promises  little  for  the  prevention  of 
venereal  disease.  Irregular  living  affects  health  quite 
apart  from  venereal  disease.  The  associated  worry  and 
the  other  associated  bad  habits  of  body  and  mind  which 
arise  from  faulty  sex  habits,  while  incapable  of  statisti- 
cal proof,  are  capable  of  producing  much  harm  to  body 
and  mind.  The  solution  of  sex  hygiene  is  the  acquisi- 
tion of  sound  sex  habits.  Sound  sex  habits  mean  the 
exercise  of  the  sex  instinct  in  the  marital  state  and, 
under  all  other  conditions,  sex  continence. 

Sex  Perversions.  There  are  other  forms  of  sex  in- 
dulgence and  sex  habits  than  those  of  sexual  intercourse 
and  these  are  grouped  together  as  sex  perversions.  The 
most  widely  known  of  these  is  masturbation,  an  un- 
natural practice  of  both  sexes.  On  account  of  the 
nature  of  this  practice  a  habit  is  easily  established.  It 
is  somewhat  difficult  to  decide  whether  it  is  fortunate  or 
unfortunate  that  most  of  the  tales  and  popular  con- 
ceptions regarding  masturbation  are  false.  These 
tales  are  terrifying  because  it  has  been  the  belief  that 
the  best  method  of  procedure  is  to  frighten  the  individ- 
ual out  of  his  perverted  habit.  The  gossip  of  youth, 
the  lurid  advertisement,  the  instinctive  reticence 
towards  such  matters,  all  conspire  to  distort  knowledge 
covering  matters  of  sex.  Such  a  normal  manifestation 


268  HEALTH  AND  DISEASE 

as  the  periodic  nocturnal  emission  of  the  continent 
male  youth  is  distorted  to  mean  sexual  weakness.  As 
a  matter  of  fact  the  nocturnal  emission  is  simply  the 
more  or  less  automatic  relief  of  the  overfilled  sex 
organs.  No  definite  interval  can  be  fixed  for  its  occur- 
rence either  in  days,  weeks,  or  months.  But  those  who 
practice  masturbation  either  sporadically  or  regularly 
are  the  particular  prey  to  weird  superstitions.  The 
facts  are  relatively  simple.  The  insane  and  feeble- 
minded masturbate  because,  on  account  of  their  in- 
sanity or  feeble-mindedness,  no  appetite  is  restrained 
while  there  are  means  of  gratification  at  hand.  In  the 
case  of  the  sexual  appetite  masturbation  is  usually 
the  most  available  means.  This  habit  is  the  result 
and  not  the  cause  of  the  insanity  and  feeble-minded- 
ness.  It  is  actually  questionable  how  much  actual 
harm  masturbation  itself  causes.  But  there  is  no 
question  that  the  natural  and  inevitable  revulsion  of 
feeling,  the  disgust  and  sense  of  shame  and  self- 
degradation  over  this  unnatural  and  indecent  practice 
may  entirely  disturb  the  mental  and  nervous  balance 
of  the  individual.  This  disturbance  is  greatly  increased 
by  ignorance,  gross  exaggeration,  and  deliberate  per- 
version of  the  facts  of  sex  hygiene.  The  victim  of 
masturbation  usually  fears  insanity,  loss  of  will  power, 
sexual  impotence,  and  inability  to  marry.  As  a  matter 
of  fact  the  habit  and  its  attendant  train  of  evils  usually 
disappear  after  simple  explanations.  The  realization 
of  the  importance  in  Nature  of  the  sex  instinct  and  the 
removal  of  the  bewildering  fog  of  mystery  and  igno- 
rance suffices  for  the  cure  of  the  habit  of  masturbation 
in  the  average  healthy  young  adult. 

Sex  Education.  The  feeling  is  growing  that  igno- 
rance is  the  cause  of  many  of  the  sexual  irregularities 
and  of  venereal  disease.  In  order  to  be  effective  this 
ignorance  must  be  dispelled  before  the  age  of  eighteen 


VENEREAL  DISEASES,  SEX  HYGIENE    269 

in  the  majority  of  cases.  The  facts  of  sex,  of  venereal 
disease,  and  of  sex  habits  should  be  put  before  all 
young  people.  But  education  will  not  eliminate  ir- 
regularities of  sexual  life.  Even  with  all  the  available 
information,  there  will  always  be  those  who  will  delib- 
erately choose  to  violate  moral  standards  and  to  expose 
themselves  to  the  physical  and  mental  damage  of 
irregular  living.  And  there  are  only  a  few  who  do  not 
bitterly  lament  when  they  incur  the  penalty  which  they 
knew  in  advance  they  were  liable  to  incur. 

It  is  highly  important  that  these  facts  of  sex  and 
health  should  not  be  colored.  A  young  adult,  made 
suspicious  of  the  truth  of  statements  about  sex,  not 
infrequently  decides  to  trust  only  to  his  own  experiences. 
If  the  young  adult  is  to  learn  by  the  experience  of 
others,  the  account  must  be  accurate  and  convincing. 
With  the  best  intentions  in  the  world  many  estimable 
people  feel  justified  in  perverting  the  truth  about  sexual 
matters,  only  too  frequently  with  disastrous  results. 
Much  excellent  literature  has  been  published  on  sex 
hygiene,  but  too  often  it  is  easy  to  misinterpret  the 
opinions  advanced.  The  main  responsibility  for  the 
elucidation  of  sex  matters  to  the  young  people  must  fall 
on  the  parent,  the  guardian,  and  the  doctor.  Pam- 
phlets, books,  and  lectures  are  often  valuable  adjuncts, 
but  the  problem  varies  in  each  boy  and  girl  and  the 
individual  difficulty  is  better  and  only  solved  by  a 
personal  interview.  The  pamphlet  read  in  secret  may 
only  serve  to  inspire  or  exaggerate  morbid  thoughts. 
Indeed,  one  of  the  greatest  difficulties  in  the  instruction 
on  sex  hygiene  is  to  prevent  the  subject  becoming 
unduly  prominent  in  the  minds  of  the  youth. 

Sound  habits  of  living  inspire  other  wholesome  habits. 
The  boy  and  girl  with  sound  health  habits  usually 
need  little  encouragement  to  develop  a  sound  habit  of 
sex.  Likewise,  unwholesome  habits  of  mind  and  body 


270  HEALTH  AND  DISEASE 

furnish  a  favorable  soil  for  the  development  of  a  faulty 
sex  habit.  Thus,  overstudy,  fatigue,  insufficient  exer- 
cise, as  well  as  frank  dissipation,  may  contribute  to  the 
formation  of  bad  habits  of  sex. 

The  encouragement  of  out-of-door  recreative  exer- 
cise and  athletic  games  finds  an  important  justification 
in  contributing  to  a  healthy  mind  and  body.  Many  a 
boy  and  girl  find  that  physical  exercise  and  sound 
physical  condition  eliminate  the  disturbance  of  the 
sex  problem.  Education  and  other  wholesome  health 
habits  contribute  the  best  basis  for  the  formation 
of  a  good  sex  habit.  Marriage,  and  particularly  early 
marriage,  represent  to  many  people  the  best  solution 
of  the  problem  of  sex.  While  marriage  permits  the 
exercise  of  the  sex  instinct  for  its  original  purpose, 
namely  the  propagation  of  children,  yet  the  problems 
of  sex  are  greater  than  the  conditions  of  marriage  and 
marriage  per  se  does  not  solve  the  sex  problem  in  every 
instance. 


CHAPTER  XV 

THE  INSECT-BORNE  DISEASES 

THE  fourth  large  group  of  communicable  diseases 
is  made  up  of  those  which  are  transmitted  by  insects. 
In  the  diseases  of  this  group,  however,  there  is  a  slight 
overlapping  into  other  methods  of  transmission.  In 
the  case  of  typhoid  fever,  for  example,  it  is  probable 
that  flies  play  a  certain  role,  but  in  the  case  of  the  im- 
portant diseases  of  this  group  they  are  only  transmitted 
by  the  bites  of  insects. 

Yellow  Fever 

The  conquest  of  yellow  fever  is  one  of  the  most 
dramatic  accomplishments  of  modern  medicine.  Al- 
most until  the  present  day  yellow  fever  has  been  the 
greatest  scourge  of  many  localities  long  inured  to  disease 
of  many  kinds.  Yellow  fever,  in  contrast  to  the  other 
communicable  diseases,  spread  over  only  a  limited 
area.  The  earliest  history  of  the  disease  comes  from 
the  followers  of  Columbus.  When  first  known  to 
white  people  the  disease  was  confined  to  the  shores  of 
the  Caribbean  Sea  and  of  the  Gulf  of  Mexico  in  the 
Western  Hemisphere.  With  the  increase  of  transporta- 
tion and  communication  yellow  fever  spread.  Epidem- 
ics have  occurred  as  far  north  as  Quebec  in  Canada,  in 
Wales  in  Great  Britain,  in  Italy,  on  the  West  Coast  of 
Africa,  and  as  far  south  as  Montivideo  and  Valparaiso 
in  South  America.  But  these  epidemics  always  origi- 

271 


272  HEALTH  AND  DISEASE 

nated  from  some  locality  in  which  yellow  fever  was 
constantly  present.  At  the  time  of  the  greatest  extent 
yellow  fever  was  constantly  present  only  in  the  limited 
area  bounded  by  Havana,  the  Canary  Islands,  the  West 
Coast  of  Africa,  Rio  Janeiro,  Brazil,  Guayaquil, 
Ecuador,  Panama,  and  Vera  Cruz,  Mexico. 

For  well  over  a  hundred  years  yellow  fever  was 
practically  constantly  present  in  Havana  and  from  this 
focus  many  portions  of  the  civilized  world  were  in- 
fected again  and  again.  In  the  latter  part  of  the  eight- 
eenth century  yellow  fever  destroyed  ten  per  cent  of 
the  population  of  Philadelphia.  More  than  once  it 
brought  military  expeditions  to  defeat  through  the 
frightful  mortality  among  the  troops.  During  the 
French  expedition  to  Haiti  in  1802,  22,000  out  of 
25,000  men  died  from  yellow  fever  in  one  season.  It 
is  said  that  out  of  a  population  of  9,000  in  Gibraltar  in 
1800,  only  twenty-eight  escaped  infection.  In  1878 
out  of  a  population  of  19,500  in  Memphis,  there  were 
17,600  cases,  with  6,000  deaths.  New  Orleans  had 
almost  yearly  epidemics  of  yellow  fever  or  "  Yellow 
Jack."  The  Isthmus  of  Panama  was  infected  with  the 
disease,  and  it  was  this  rather  than  any  lack  of  engineer- 
ing skill  which  caused  the  failure  of  the  French  to  com- 
plete the  Canal.  The  French  yearly  lost  one-third  of 
their  white  force  from  this  cause.  During  the  occupa- 
tion of  Cuba  by  the  United  States  troops  in  the  Spanish- 
American  war,  the  troops  suffered  as  severely  as  the 
troops  of  a  hundred  years  before. 

Shortly  after  the  Spanish-American  war  the  real  his- 
tory of  yellow  fever  was  written.  At  that  time  the 
only  known  factors  in  regard  to  the  disease  were  as 
follows.  Yellow  fever  was  always  much  more  prevalent 
in  the  hot  weather.  A  person  who  survived  an  attack 
of  the  disease  was  thereafter  immune.  Immunes  were 
in  great  demand  in  the  yellow  fever  districts,  for  the 


THE  INSECT-BORNE  DISEASES        273 

mortality  of  the  disease  averaged  about  twenty-five 
per  cent. 

At  the  beginning  of  the  American  occupation  of 
Havana  the  city  was  scrubbed  and  cleaned  and  the 
best  known  sanitary  regulations  were  thoroughly  carried 
out  under  military  authority.  And  yet,  to  the  dismay 
of  the  sanitarians  and  to  the  amusement  of  the  Cubans, 
who  had  been  seriously  inconvenienced  by  this  cleaning 
up  process,  yellow  fever  became  more  prevalent  than 
ever.  The  result  was  the  Yellow  Fever  Commission, 
constituted  of  Dr.  Reed,  as  chairman,  and  Drs.  Lazear, 
Carroll,  and  Agramonte,  which  began  work  in  1900. 
Within  two  years  all  the  essential  facts  necessary  to 
prevent  the  disease  were  discovered,  but  Lazear  died 
of  yellow  fever,  Carroll  intentionally  contracted  the 
disease  for  experimental  purposes,  and  a  number  of 
volunteers  willingly  exposed  themselves  to  the  disease 
under  all  conditions.  From  this  exposure  the  usual 
proportion  of  those  who  contracted  the  disease  died. 
These  men  voluntarily  faced  death,  not  in  the  excite- 
ment of  battle,  but  in  the  quiet  of  a  scientific  labora- 
tory. Since  yellow  fever  was  not  transmissible  to 
animals,  proof  of  the  method  of  transmission  had  to 
be  secured  from  human  beings.  But  these  heroic 
sacrifices  were  happily  not  in  vain,  for  they  directly 
resulted  in  the  saving  of  thousands  of  lives  each  year, 
in  the  prevention  of  enormous  economic  losses,  and  in 
the  building  of  the  Panama  Canal. 

The  mosquito  had  long  been  under  suspicion  as  the 
carrier  of  yellow  fever,  and  the  experimental  work  soon 
demonstrated  that  only  one  species  of  mosquito,  the 
female  stegomyia  fasciata,  transmits  the  disease.  The 
patient  with  yellow  fever  has  to  be  bitten  within  the 
first  three  days  of  the  attack  for  transmission  to  be 
possible.  After  taking  the  blood,  the  mosquito  does 
not  transmit  the  disease  until  twelve  days  later. 


274  HEALTH  AND  DISEASE 

After  twelve  days  the  bite  of  the  mosquito  seems  to 
transfer  the  disease  during  the  life  of  the  mosquito. 
Yellow  fever  is  transmitted  in  no  other  way,  as  was 
proved  by  the  courageous  volunteers,  who  spent  weeks 
sleeping  and  living  in  rooms  on  the  soiled  bedding  of 
recent  yellow  fever  patients,  without  contracting  the 
disease,  always  provided  no  stegomyia  mosquito  entered. 

Since  the  disease  is  transmitted  by  mosquitoes  and 
only  by  a  certain  species  of  mosquito,  it  is  not  remark- 
able that  cleaning  up  Havana  did  not  rid  the  city  of 
yellow  fever.  As  a  result  of  the  experimental  work, 
attention  was  at  once  turned  on  the  mosquito.  The 
stegomyia  is  found  from  Parallel  38°  south  and  north. 
The  insect  resembles  somewhat  the  common  culex 
mosquito  of  the  Atlantic  coast,  but,  on  close  examina- 
tion, the  stegomyia  has  white  markings  and  stripes, 
which  give  it  a  general  grayish  appearance.  The 
stegomyia  mosquito  never  appears  further  north  than 
Norfolk,  Virginia,  except  by  some  unusual  accident 
of  transfer.  The  insect  has  little  flying  ability  and  is 
easily  destroyed  by  a  breeze.  The  stegomyia  is  essen- 
tially a  house  insect,  with  a  short  life,  and  it  breeds 
rapidly  during  hot  weather  in  rain-water  barrels, 
cisterns,  wells,  and  house-gutters. 

Acting  on  these  facts  concerning  the  cause  of  yellow 
fever,  energetic  measures  were  taken  in  Havana  against 
the  mosquitoes  in  general  and  particularly  against 
their  breeding  places.  This  meant  the  use  of  screens, 
especially  about  yellow  fever  patients.  It  meant  the 
emptying  or  screening  of  all  stagnant  water,  if  that 
were  possible,  and  the  pouring  of  oil  on  any  permanent 
stagnant  water  to  destroy  the  larvae  of  the  mosquitoes. 
Fumigation  with  sulphur  and  other  substances  was 
found  to  be  effective  in  killing  mosquitoes  in  houses, 
particularly  after  a  case  of  yellow  fever.  The  result  of 
these  measures  was  almost  incredibly  prompt  and 


THE  INSECT-BORNE  DISEASES        275 

brilliant.  The  yearly  toll  of  deaths  from  yellow  fever 
in  Havana  was  over  500.  And  there  has  been  only 
one  case  since  September,  1901 ! 

In  May,  1904,  the  United  States  took  over  the  build- 
ing of  the  Panama  Canal,  and,  incidentally,  the  yellow 
fever  of  the  Isthmus.  Under  the  able  sanitary  super- 
vision of  Colonel,  now  Surgeon  General,  Gorgas,  there 
has  been  no  case  of  yellow  fever  in  the  Canal  Zone 
since  May,  1906. 

The  weapons  for  the  control  and  elimination  of  yellow 
fever  are  readily  available  as  the  experience  in  Havana 
and  in  the  Canal  Zone  shows.  And  yet  the  actual  causa- 
tive agent  of  yellow  fever  is  still  undiscovered !  It  is 
know  to  be  extremely  small,  ultra-microscopic,  as  it 
readily  passes  through  a  fine  filter.  But  the  knowledge 
of  the  causative  agent  is  not  necessary  for  the  eradica- 
tion of  the  disease  since  we  know  and  can  control  the 
means  of  communication. 

Malaria 

Malaria  has  been  known  for  more  than  2,000  years, 
both  under  its  usual  name  which  means  "  bad  air  " 
and  under  its  many  synonyms,  as  chills  and  fever  and 
ague.  Malaria  is  prevalent  in  all  tropical  countries 
and  becomes  less  common  in  colder  regions.  In  India, 
an  example  of  a  tropical  country,  the  disease  has  killed 
millions,  and  in  the  United  States  there  are  probably 
a  million  cases  of  the  disease,  mostly  in  the  South. 
While  malaria,  as  a  rule,  is  not  fatal,  certain  forms  are 
notoriously  so.  The  disease  shows  little  tendency 
to  spontaneous  cure  and  one  attack  does  not  prevent 
a  second.  In  fact,  after  infection,  many  persons  in- 
adequately treated  suffer  at  irregular  intervals  from 
malaria  for  the  rest  of  their  lives.  It  causes  a  large 
amount  of  invalidism  and  industrial  inefficiency.  For 


276  HEALTH  AND  DISEASE 

many  years  a  remarkable  remedy,  cinchona  bark  and 
its  active  principle,  quinine,  have  been  known,  being 
introduced  into  England  as  early  as  1649,  but  the 
essential  facts  of  the  disease,  the  infecting  agent,  and 
the  method  of  transmission  have  been  known  only 
recently. 

Just  as  yellow  fever  is  transmitted  by  a  particular 
mosquito,  so  is  malaria  transferred  by  a  mosquito,  the 
anopheles .  Like  the  stegomyia,  the  anopheles  mosquito 
has  certain  definite  characteristics,  among  them  long 
hind  legs  which  cause  the  insect  at  rest  to  appear  to  be 
standing  on  its  head.  The  anopheles  is  hardier  than 
the  stegomyia,  but  is  not  capable  of  long  flights.  The 
culex,  the  non-disease  carrier,  on  the  other  hand,  can 
fly  for  twenty  miles.  The  anopheles  is  a  country  mos- 
quito and  breeds  in  fresh  water  where  there  are  weeds 
and  algae.  Experience,  therefore,  had  rightly  asso- 
ciated malaria  with  swamps,  but  it  was  not  the  air 
from  the  swamp,  but  the  swamp  as  a  breeding  place 
for  this  one  breed  of  mosquito.  In  order  to  destroy 
anopheles  mosquitoes  the  same  principles  hold  true 
as  for  the  stegomyia.  Only  with  the  anopheles  it  is 
necessary  to  drain  swamps,  cut  down  underbrush,  and 
oil  large  areas  of  stagnant  country  water. 

The  cause  of  malaria,  which  was  discovered  after 
the  association  of  malaria  with  the  mosquito,  is  a  small 
animal  parasite  which  goes  through  a  definite  cycle. 
There  is  one  cycle  for  the  human  host,  and  another  for 
the  animal  host.  It  is  usually  possible  to  demonstrate 
the  malarial  plasmodia  in  the  blood  of  persons  with 
malaria  and  the  blood  examination  is  a  valuable  means 
of  making  a  correct  diagnosis  of  the  disease. 

With  a  knowledge  of  these  facts  it  would  seem  to  be 
possible  to  stamp  out  malaria,  but  the  reason  for  the 
contrary  is  a  simple  one.  Yellow  fever,  which  has 
been  controlled,  is  a  short  fever  and  the  patient  is 


THE  INSECT-BORNE  DISEASES        277 

infectious  for  less  than  a  week  and  the  mosquito  must 
bite  the  patient  during  that  time  to  transfer  the  disease. 
On  the  other  hand  malaria  is  a  chronic  disease.  It  is 
easy,  during  the  dangerous  few  days,  to  isolate  a  person 
suffering  with  yellow  fever  and  screen  him  from  mos- 
quitoes, because  he  is  almost  necessarily  confined  to 
bed  with  the  illness.  Such  procedure  is  not  possible 
with  people  suffering  from  malaria  for  many  of  them  lead 
active  lives  and  harbor  the  plasmodia  for  years,  and 
thus  may  furnish  infected  blood  to  many  anopheles 
mosquitoes.  These  insects  have  a  wider  range  into 
the  Temperate  zone,  are  hardier,  and  their  breeding 
places  are  more  difficult  to  eliminate  than  is  the  case 
with  the  stegomyia  mosquito.  As  a  partial  recompense 
for  the  difficulties  of  controlling  malaria  carriers  and 
of  exterminating  the  anopheles,  we  have  in  quinine 
not  only  a  drug  of  remarkable  value  as  a  cure,  but  also 
as  a  prophylactic.  Then,  too,  Salvarsan  frequently  has 
the  same  effect  upon  the  malarial  plasmodia  as  it  has 
upon  the  spirochseta  pallida.  This  drug  goes  through 
the  body,  searches  out  the  malarial  parasites,  and  kills 
them  off  without  injury  to  the  organs  of  the  body. 
Quinine  also  attacks  the  malarial  parasites  and  kills 
them.  Thus  we  have  a  marked  and  specific  action  of 
a  drug  which  can  only  be  paralleled  by  the  natural 
antibodies  of  the  body.  The  prompt  use  of  quinine 
in  malaria  will  kill  the  plasmodia  and  eliminate  a 
reservoir  for  the  mosquito  to  tap  and  transfer. 
Furthermore,  quinine  may  act  as  a  preventive  of  the 
disease,  although  this  statement  requires  some  modifi- 
cations. General  Gorgas  advocates  the  daily  adminis- 
tration of  five  grains  of  quinine  as  a  prophylactic  in 
malarial  districts. 

In  Havana  before  1901  there  were  yearly  between  300 
and  500  deaths  from  malaria,  reaching  as  high  as  1,900 
in  1898.  By  the  use  of  various  antimalarial  measures, 


278  HEALTH  AND  DISEASE 

proper  screening,  drainage  or  oiling  of  breeding  places, 
intelligent  use  of  quinine  both  as  a  curative  and  as  a 
prophylactic,  and  the  widespread  use  of  blood  examina- 
tion for  diagnosis,  there  were  only  four  deaths  in  1912. 
Malaria  still  exists  in  the  Canal  Zone,  but  it  is  under 
reasonable  control.  In  1906  over  eighty  per  cent  of 
the  employees  went  to  the  hospital  suffering  from 
malaria.  In  1913  the  percentage  was  only  7.6  per  cent. 

A  malarial  district  in  one  of  the  Southern  states 
has  recently  undertaken  an  intensive  warfare  against 
malaria.  As  far  as  possible  all  persons  were  subjected 
to  a  blood  examination  for  the  disease.  While  not  all 
persons  with  malaria  constantly  show  the  parasite  in 
the  blood,  most  of  them  do.  One  of  the  remarkable 
features  in  this  experiment  was  that  many  persons  who 
seemed  to  be  in  good  health  harbored  malarial  parasites. 
Obviously  all  persons  with  malarial  organisms  in  the 
blood  are  possible  carriers  of  the  disease.  Consequently 
they  were  treated  with  quinine  and  were  guarded,  as 
far  as  possible,  while  they  had  the  parasites  in  the  blood, 
from  the  bites  of  the  anopheles  mosquito.  Further- 
more, vigorous  anti-mosquito  measures  were  under- 
taken along  the  lines  employed  in  the  Canal  Zone. 
Swamps  and  stagnant  waters  were  drained;  under- 
brush was  cut  away,  and  the  remaining  open  water  was 
oiled.  Such  a  program  is  obviously  expensive,  but  in 
the  end  will  easily  justify  itself  in  the  saving  of  money, 
health,  and  life. 

The  problem  of  malaria  is  not  only  a  community 
problem,  but  also  a  personal  one.  The  community 
can  largely,  but  not  entirely,  exterminate  the  anopheles 
mosquito.  But  the  individual  also  has  a  problem 
toward  the  mosquito.  In  the  Tropics  and  in  any  ma- 
larial or  anopheles  district,  the  individual  can  usually 
protect  himself  by  a  proper  mosquito  net  so  applied  as 
to  keep  out  the  mosquitoes.  Communities  and  indi- 


THE  INSECT-BORNE  DISEASES        279 

viduals,  however,  are  only  slowly  applying  the  available 
knowledge  to  the  prevention  of  malaria,  but  the 
examples  of  Havana  and  the  Canal  Zone  have  accom- 
plished much  for  sanitary  education. 

The  commercial  value  of  the  Tropics  in  the  Western 
Hemisphere  is  great  and  it  has  been  practically  un- 
touched on  account  of  malaria  and  yellow  fever.  The 
future  will  probably  see  further  demonstrations  of  the 
fact  that  business,  often  shortsighted  in  matters  of 
health,  is  gradually  recognizing  the  economic  value  of 
health.  The  same  methods  which  made  the  Panama 
Canal  possible  and  turned  the  Canal  Zone  from  a 
pestilential  hole  into  a  health  resort  will  make  inten- 
sive business  possible  in  the  hitherto  impossible  Tropics. 

Bubonic  Plague 

On  account  of  its  high  mortality  rate  and  the  tremen- 
dous ravages  which  its  epidemics  have  caused  from  time 
to  time,  the  bubonic  plague  is  rightfully  one  of  the  most 
dreaded  of  the  communicable  diseases  and  one  most 
rigidly  guarded  against  by  health  authorities.  Plague 
has  been  known  since  the  earliest  times.  The  Roman 
world  was  twice  devastated  by  the  disease  and  about 
542  A.D.  Egypt  had  a  violent  epidemic  which  lasted 
for  a  considerable  number  of  years.  In  1347  plague, 
called  "  Black  Death ",  ravaged  Europe  and  some 
25,000,000  people,  about  one-fourth  of  the  population, 
lost  their  lives.  Another  outbreak  occurred  in  London 
in  1665  which  destroyed  some  70,000  lives.  This  was 
the  epidemic  which  inspired  DeFoe's  "Journal  of  the 
Plague  Year."  The  latest  great  epidemic  of  plague 
started  in  Canton  and  Hong  Kong,  China,  in  1894. 
In  Canton,  where  the  disease  had  never  occurred 
before,  it  killed  180,000.  In  1896  the  disease  reached 
Bombay  and  in  all  India  since  then  there  are  said  to 


280  HEALTH  AND  DISEASE 

have  been  over  5,500,000  cases  with  a  death  rate  of 
slightly  over  ninety  per  cent.  The  plague  continued 
its  travels  and  in  1899  reached  New  York  and  South 
America.  The  disease  has  been  endemic  in  South 
America  ever  since.  In  1900  the  plague  appeared  in 
San  Francisco  and  there  were  twenty-two  deaths  that 
year,  twenty-five  in  1901,  and  forty-one  in  1902. 

The  plague  is  caused  by  a  specific  bacillus,  the  bacillus 
pestis.  The  disease  is  now  known  to  be  one  peculiar 
to  rats  and  apparently  only  secondarily  and  acciden- 
tally transferred  to  other  animals,  including  man.  The 
usual  method  of  transferring  the  disease  is  through  the 
flea.  Certain  fleas  inhabit  man  or  animals  indifferently. 
Bubonic  plague  (glandular  plague)  is  apparently  always 
transmitted  by  fleas.  In  the  course  of  bubonic  plague, 
however,  at  least  two  other  forms  of  plague  appear  in  a 
small  percentage  of  the  cases,  pneumonic  and  septi- 
cemic  plague.  Pneumonic  plague  may  occur  in  epidem- 
ics like  the  one  in  Manchuria  studied  by  Strong.  In 
septicemic  and  bubonic  plague  the  bacteria  are  sealed 
up,  as  it  were,  in  the  body  and  apparently  do  not  appear 
in  the  secretions.  In  these  forms  of  plague,  therefore, 
man  is  only  dangerous  through  the  agency  of  the  flea. 
In  the  pneumonic  plague,  on  the  contrary,  the  bacilli 
are  coughed  out  in  enormous  numbers  and  the  infection 
spreads  from  man  to  man  through  the  air  in  droplets. 
So  far  as  is  known  no  one  has  ever  recovered  from 
pneumonic  plague.  The  mortality  of  the  common 
form  of  plague,  on  the  other  hand,  varies  from  sixteen 
to  ninety  per  cent,  averaging  in  epidemics,  not  far 
from  seventy -five  per  cent.  One  attack  of  the  disease 
usually  renders  a  person  immune  for  life,  so  that  there 
have  been  many  attempts  to  secure  a  curative  serum 
and  a  vaccine.  Yersin's  anti-plague  serum  has  a  mild 
curative  property  and  a  slight  temporary  protective 
action  and  is  of  little  practical  use.  Haffkine's  vaccine 


THE  INSECT-BORNE  DISEASES        281 

is  of  considerable  value  as  it  affords  moderate  but  by  no 
means  complete  protection  and  reduces  rather  markedly 
the  mortality  of  the  disease  in  those  vaccinated. 

Plague  prevention  consists  of  warfare  on  rats  and 
fleas  in  general  and  the  prevention  of  the  spread  of 
plague  among  rats  and  from  rats  to  other  animals  and 
man.  Much  of  our  knowledge  concerning  bubonic 
plague  and  measures  for  its  prevention  is  derived 
from  the  admirable  work  of  the  United  States  Public 
Health  Service  in  California,  originally  under  Dr. 
Rupert  Blue,  now  surgeon  general  of  the  public  health 
service.  This  plague  prevention  work  in  California  has 
cost  millions  of  dollars  but  it  has  undoubtedly  pre- 
vented terrible  epidemics  of  the  dread  disease.  In 
California  the  plague  was  transmitted  from  rats,  pre- 
sumably by  fleas,  to  the  ground  squirrels.  At  the  present 
time  these  squirrels  show  plague  in  a  small  percentage 
of  cases,  but  plague  does  not  exist  in  the  city  rats. 
Human  plague  has  actually  been  traced  to  plague  in 
ground  squirrels  transmitted  by  fleas  so  that  it  is  neces- 
sary to  prevent  the  re-introduction  of  plague  into  the 
city  rats.  Squirrel-free  zones  about  cities  are  main- 
tained; ground  squirrels  and  rats  are  destroyed  as 
far  as  possible,  and  houses  and  buildings  are  built  rat 
proof.  Finally,  ships  from  the  plague-infested  Orient 
are  rid  of  rats  which  might  introduce  plague.  Similar 
measures  have  been  very  effective  in  Manila  and  in 
selected  areas  in  the  Orient.  While  plague  continues 
to  exist  in  many  parts  of  the  world,  we  now  possess  the 
adequate  knowledge  to  make,  in  the  future,  any  world- 
wide epidemic  of  plague  or  black  death  impossible. 

Typhus  Fever 

The  attention  of  the  world  has  been  recently  attracted 
to  typhus  fever  through  the  striking  and  devastating 


282  HEALTH  AND  DISEASE 

epidemic  in  Serbia,  but  the  disease  has  been  known  for 
a  long  time.  Formerly  it  was  much  more  prominent 
than  typhoid  fever  is  to-day.  Typhus  fever  has  been 
known  under  the  names  of  "  Jail  Fever  "  and  "  Filth 
Fever."  It  is  essentially  a  filth  disease  associated  with 
the  overcrowding  of  people,  with  great  armies,  during 
famines,  and  on  ships  in  which  the  crew  or  passengers 
are  huddled  together  for  a  long  time.  There  were 
several  epidemics  of  typhus  in  the  last  half  of  the  six- 
teenth century,  during  the  eighteenth  century,  and  in 
the  early  part  of  the  nineteenth  century  in  various  parts 
of  Europe.  During  this  period  typhus  was  a  constant 
source  of  terror  in  the  jails  and  in  the  centers  of  popula- 
tion. In  1846  a  virulent  epidemic  of  typhus  ravaged 
Ireland  and  England.  The  disease  first  appeared  in 
America  in  New  England  in  1807.  Its  last  appearances 
in  epidemic  form  in  this  country  were  in  New  York 
1881-82  and  in  1892-93  and  in  Philadelphia  in  1883. 
The  disease  prevails  extensively  in  Mexico,  and  is 
always  present  in  Persia,  China,  Hungary,  and  Turkey. 

The  causative  organism  of  typhus  fever  is  as  yet 
undiscovered,  and,  consequently,  there  is  frequently 
considerable  difficulty  in  making  an  accurate  diagnosis. 
It  has  recently  been  established,  however,  that  the 
typhus  fever  of  the  Old  World  and  the  typhus  fever 
of  Mexico  are  identical.  Furthermore,  we  have  con- 
stantly with  us  here  in  the  United  States  a  mild  form  of 
typhus  fever  usually  known  as  Brill's  disease.  The 
writer  has  reported  nearly  thirty  cases  which  were 
treated  in  the  Massachusetts  General  Hospital  in  the 
course  of  ten  years. 

The  association  of  typhus  fever  with  filthy  living 
conditions  was  followed  in  due  time  by  the  discovery 
that  the  disease  is  transmitted  from  person  to  person 
by  lice.  The  recent  Serbian  epidemic,  as  well  as 
other  previous  epidemics,  are  associated  with  conditions 


THE  INSECT-BORNE  DISEASES        283 

favoring  the  increase  and  spread  of  lice.  Preventive 
measures  are  directed  against  the  louse  and  the  isola- 
tion of  patients  from  lice.  Cleanliness  of  the  person 
and  the  extermination  of  lice  in  clothes  and  bedding 
prevent  the  spread  of  typhus  fever. 

Filariasis 

Elephantiasis,  while  occasionally  due  to  other  causes, 
is  usually  the  important  symptom  of  a  disease  which  is 
probably,  but  not  certainly,  transmitted  by  the  mos- 
quito. The  disease  is  peculiar  to  the  tropical  and  sub- 
tropical regions  where  it  is  very  common.  The  direct 
cause  is  a  thread-like  animal  parasite,  filaria,  which  is 
communicated  to  the  individual  by  mosquito  bites. 
The  usual  prominent  symptom  is  the  permanent  enor- 
mous swelling  of  one  or  both  legs  and,  in  the  male,  of 
the  scrotum. 

Dengue 

Dengue  is  a  common,  but  not  fatal,  short  febrile 
disease  of  tropical  and  sub-tropical  countries.  The 
cause  is  unknown,  but  the  disease  is  probably  trans- 
ferred by  mosquitoes. 

Sleeping  Sickness 

Sleeping  sickness  is  largely  a  disease  of  tropical 
Africa,  especially  about  the  Congo  River.  It  may  run 
a  course  of  years  and  derives  its  name  from  the  principal 
symptoms.  The  disease  is  caused  by  an  animal  para- 
site, the  trypanosoma,  which  is  carried  by  the  biting 
of  the  tsetse  fly.  The  mortality  of  the  sleeping  sick- 
ness is  apparently  one  hundred  per  cent  and  it  has 
killed  hundreds  and  hundreds  of  thousands  of  natives 
in  Africa.  The  tsetse  fly  lives  in  the  grass  and  bites 


284 

at  night  and  the  protection  against  it  is  the  same  as 
for  malarial  insects.  The  extermination  of  the  tsetse 
fly  in  tropical  Africa  is  at  present  impossible  and  most 
of  the  protection  is  afforded  by  individual  precautions 
against  all  biting  insects. 

Diseases  Caused  by  Ticks 

The  ticks  transmit  certain  diseases.  The  best 
known  of  these  diseases  are  Texas  fever  of  cattle 
(chiefly  interesting  as  being  the  first  disease  traced  to 
ticks),  Rocky  Mountain  spotted  fever  which  occurs, 
as  the  name  indicates,  particularly  in  Montana,  Idaho, 
and  Wyoming,  and  relapsing  fever,  which  seems  to 
be  carried  by  other  biting  insects  as  well  as  a  peculiar 
African  tick  fever. 

Leischmaniasis 

Peculiar  micro-organisms,  known  as  Leischman- 
Donovan  bodies,  are  the  cause  of  a  group  of  diseases  not 
yet  well  defined.  There  is  evidence  to  support  the 
view  that  some  members,  at  least,  of  this  group,  notably 
Kala-Azar  or  dum-dum  fever  of  India,  a  common  and 
highly  fatal  disease  with  anemia  and  large  spleen,  and 
a  similar  disease  among  children  in  the  Greek  islands 
are  spread  by  the  bites  of  fleas  or  bedbugs. 

The  role  of  insects  in  transmitting  disease  is  a  recent 
discovery,  and  probably  the  list  of  diseases  so  trans- 
mitted is  not  yet  complete,  although  it  is  already  for- 
midable. Malaria,  yellow  fever,  dengue,  and  filariasis 
are  transmitted  by  mosquitoes.  Sleeping  sickness  is 
transmitted  by  the  tsetse  fly;  bubonic  plague  by  the 
flea;  typhus  by  the  louse,  and  certain  specific  fevers 
by  ticks.  Then  the  fly  with  its  filthy  habits  may  spread 
various  diseases,  such  as  typhoid  fever.  All  in  all  the 


THE  INSECT-BORNE  DISEASES        285 

indictment  against  insects,  especially  the  biting  insects, 
is  serious.  It  is  because  insects  flourish  in  the  Tropics 
that  so  many  of  the  insect-borne  diseases  are  tropical. 
Before  the  Tropics  can  be  made  healthy,  some  means 
must  be  found  to  eliminate  or  reduce  the  insect  carriers 
of  disease.  But  our  knowledge  gives  us  a  guarantee 
that  the  future  will  see  no  more  worldwide  epidemics 
of  yellow  fever,  typhus  fever,  or  bubonic  plague. 


CHAPTER  XVI 

DISEASES  IN  WHICH  THE  METHOD  OP  SPREAD  is 

UNKNOWN 

THERE  are  a  number  of  diseases  in  which  the  channel 
of  infection  and  the  method  of  spread  are  entirely  un- 
known. There  seems  to  be  no  doubt  that  the  diseases 
are  communicable,  but  how  the  infection  passes  from 
person  to  person  has  not  been  solved.  In  these  diseases 
we  find  illustrated  the  fact  that  ignorance  and  mystery 
are  active  sources  of  fear,  for  the  two  main  diseases  in 
this  group — infantile  paralysis  and  leprosy —  have  both 
been  the  cause  of  popular  hysteria  and  of  unreasoning 
panic.  It  is  not  remarkable,  however,  that  people 
especially  dread  those  things  which  spring  up  myste- 
riously and  which  cause  devastation,  but  against  which 
there  seems  to  be  not  only  no  certain  but  also  no  logical 
protection. 

Infantile  Paralysis 

Infantile  paralysis  (acute  anterior  poliomyelitis)  is 
now  regarded  as  a  communicable  disease,  although  the 
exact  method  of  transfer  has  yet  to  be  discovered.  As 
the  name  indicates,  sufferers  from  this  disease  develop 
paralysis,  which,  in  a  majority  of  cases  —  roughly  sixty 
per  cent  —  continues  through  life.  About  half  of  the 
remainder  die  and  the  rest  recover  completely.  In 
some  epidemics  the  mortality  has  run  as  high  as  twenty- 
five  per  cent,  while  in  others  only  eight  per  cent  died. 
The  disease  mainly  attacks  the  young,  the  large 

286 


INFANTILE  PARALYSIS  287 

majority  of  the  cases  being  under  six  years  of  age, 
while  it  is  extremely  rare  in  persons  over  thirty  years 
of  age.  The  main  incidence  of  the  disease  is  during 
warm  weather  and  in  localities  with  a  wide  range  of 
climate.  Until  the  epidemic  of  1916  infantile  paralysis 
had  been  rather  more  prevalent  in  towns  and  in  country 
districts.  No  class  of  society  is  immune  from  attack. 

Infantile  paralysis  has  been  known  since  the  earliest 
Egyptian  times,  but  in  its  modern  aspect  the  disease 
had  become  of  importance  only  very  recently.  The 
first  great  epidemic  of  infantile  paralysis  of  modern 
times  occurred  in  Norway  and  Sweden  in  1905,  some 
2,000  cases  being  reported.  In  1907  came  the  first 
great  epidemic  in  the  United  States,  2,500  cases  being 
reported  about  New  York  and  about  2,900  cases  in 
the  country.  In  1909,  after  1908  with  only  392  cases, 
there  was  another  outbreak  with  2,345  cases.  By  1910 
the  disease  had  reached  forty-three  of  the  states.  In 
that  year  there  were  1,459  deaths  from  the  disease  in 
the  registration  area  of  the  United  States,  with  approxi- 
mately 9,000  cases. 

During  the  summer  of  1916  there  was  an  epidemic  of 
infantile  paralysis  in  New  York  with  approximately 
10,000  cases.  The  mortality  rate  was  unusually  high, 
over  twenty-five  per  cent.  On  account  of  the  rather 
striking  effects  of  the  disease  and  the  inability  to  cure 
or  to  effect  a  stop  to  its  spread,  infantile  paralysis 
created  a  panic  in  many  localities.  Regrettable  as  the 
situation  was,  it  should  be  remembered  that  this  plague 
caused  only  a  fraction  of  the  deaths  which  resulted 
during  the  same  period  from  poor  milk,  deaths  which 
were  entirely  preventable. 

The  ultra-microscopic  virus  which  causes  infantile 
paralysis  has  been  discovered,  but  little  else  is  known 
about  the  disease.  The  mode  of  transmission  is  prob- 
ably some  curious  method  of  contact  from  person  to 


288  HEALTH  AND  DISEASE 

person,  since  only  a  small  proportion  of  those  in  inti- 
mate contact  with  the  cases  contract  the  disease.  We 
are  also  without  an  effective  method  of  treatment, 
although  injections  of  serum  from  patients  who  have 
recovered  from  the  disease  seem  to  have  a  slight  bene- 
ficial effect. 

The  1916  epidemic  in  the  United  States  has  brought 
out  two  important  facts.  In  the  first  place  examination 
of  the  spinal  fluid  obtained  by  spinal  puncture  showed 
that  there  are  many  cases  of  infantile  paralysis  which 
are  never  paralyzed.  In  other  words  paralysis  is  not 
a  necessary  symptom  of  the  disease.  These  cases 
without  paralysis  had  all  the  other  clinical  symptoms 
and  could  only  be  positively  diagnosticated  by  the 
examination  of  the  spinal  fluid.  The  second  important 
fact  was  the  establishing  of  a  more  or  less  close  associa- 
tion of  many  cases  with  previous  cases.  In  this 
epidemic  the  hitherto  unrecognized  cases  without 
paralysis  often  made  the  connection  between  cases. 
These  findings  confirmed  the  earlier  studies  in  the 
Scandinavian  countries,  where  the  evidence  pointed 
strongly  to  the  transmission  of  the  disease  from  person 
to  person.  Since  the  virus  is  present  in  the  mucous 
membrane  of  the  nose,  suspicion  is  naturally  directed 
towards  the  droplet  method  of  infection.  But  as  yet 
the  precise  method  of  transmission  is  undetermined. 
There  is  some  evidence  that  there  are  healthy  carriers. 
In  addition  there  is  some  evidence,  not  substantiated 
in  the  1916  epidemic,  indicating  that  the  disease  may 
be  transferred  by  a  biting  insect,  the  stable  fly. 

We  have  little  positive  knowledge  upon  which  to  base 
intelligent  precautions  against  the  spread  of  infantile 
paralysis.  It  is  reasonable  to  take  all  the  usual  pre- 
cautions which  we  employ  in  diseases  transmitted  in 
food  and  drink,  by  droplets  and  in  the  air,  by  contact, 
direct  and  indirect,  and  by  insects.  Carriers  should  be 


LEPROSY  289 

guarded  against.  These  precautions  entail  strict  isola- 
tion which  cannot  fail  to  be  effective.  We  must  await 
more  knowledge  of  the  method  of  spread  of  the  disease 
before  we  can  hope  to  combat  it  with  any  marked  degree 
of  success. 

Leprosy 

Leprosy  is  a  disease  which  has  caused  the  greatest 
apprehension  to  all  races  and  to  all  peoples  since  the 
beginnings  of  history.  The  cry  of  :<  Unclean,  un- 
clean !  "  is  present  in  the  earliest  literature  and  the 
picture  of  the  outcast  ringing  his  bell  to  warn  all 
passersby  of  his  contaminating  presence  is  equally 
familiar.  These  practices  typify  the  horror  and  loath- 
ing with  which  leprosy  and  lepers  have  always  been 
regarded.  Probably  the  first  records  of  the  disease 
are  found  in  the  Egyptian  papyri  of  4260  B.C.  The 
Bible,  in  the  Book  of  Leviticus,  gives  a  detailed  de- 
scription of  the  disease  and  suggests  the  measures  of 
segregation  which  even  at  that  date  were  used  to 
control  leprosy.  In  India  and  China,  where,  even 
to-day,  there  are  the  largest  numbers  of  lepers,  the  first 
description  appears  about  700  B.C.  In  the  Middle 
Ages  leprosy  was  epidemic  in  Europe. 

At  the  present  time  there  are  about  3,000,000  lepers 
in  the  world  and  few  countries  are  free  from  the  disease. 
China  has  about  2,000,000  lepers;  India  200,000  and 
Japan  20,000.  The  United  States,  Hawaii,  and  the 
Philippine  Islands  all  have  cases.  There  are  probably 
several  thousand  cases  of  leprosy  in  the  United  States, 
although,  on  account  of  the  rarity  of  the  disease,  cases 
are  not  always  recognized.  Practically  all  cases  of 
leprosy  in  this  country  were  contracted  elsewhere. 

Leprosy  is  caused  by  a  definite  bacillus  which  closely 
resembles  the  tubercle  bacillus.  The  mode  of  trans- 
mission is  entirely  unknown,  but  we  are  certain  that 


290  HEALTH  AND  DISEASE 

it  is  communicable,  for  people  who  have  taken  care  of 
patients  have  contracted  the  diesase. 

The  repulsive  character  of  the  disease  early  drove 
communities  to  take  drastic  measures  to  prevent  its 
spread.  These  measures  consisted  in  the  complete 
and  rigorous  isolation  of  lepers,  so  that  all  precautions 
were  taken  against  all  possible  methods  of  transmitting 
the  disease.  Such  measures  were  undertaken  in  the 
belief  that  leprosy  was  highly  infectious.  As  a  matter 
of  fact  there  is  abundant  evidence  that  the  disease 
ranks  rather  low  as  a  communicable  disease.  The 
leper  may  give  off  millions  of  bacteria  in  coughing, 
yet  cases  of  infection  among  doctors  and  nurses  are 
extremely  rare.  Nevertheless  the  strict  isolation, 
though  perhaps  unnecessarily  cruel,  is  very  effective 
against  leprosy  as  against  any  other  infectious  disease. 
It  is  worthy  of  remark  that,  impelled  by  fear,  the  public 
at  large  has  insisted  on  every  known  precaution  and 
extreme  isolation  only  in  this  disease  which  has  a  low 
infectiousness.  Leprosy  is  essentially  chronic  and 
essentially  fatal,  though  proven  cures  have  occurred. 
Until  we  know  the  method  by  which  the  disease  is 
spread,  the  stringent  isolation,  while  perhaps  unneces- 
sary, may  be  wisely  continued. 


CHAPTER  XVII 

GENERAL  CONSIDERATIONS  IN  COMMUNICABLE 
DISEASES 

IT  has  become  the  fashion  loudly  to  proclaim  that 
all  the  communicable  diseases  are  preventable.  Theo- 
retically this  is  true,  but  practically  it  is  not.  The 
prevention  of  disease  depends  on  the  characteristics 
of  each  disease.  So  the  prevention  of  communicable 
disease  does  not  permit  of  generalization. 

Formerly  it  was  argued  that  the  person  sick  with  a 
communicable  disease  represented  the  only  source  of 
danger.  At  first  contagion  or  touching  seemed  to  be 
the  sole  method  of  transferring  disease.  Then  the  air 
received  its  share  of  blame.-  Of  course  the  infected 
person,  directly  or  indirectly,  is  the  sole  source  of  most 
of  the  communicable  diseases,  but  in  some  instances 
we  have  to  guard  against  his  excretions,  which  may  be 
carried  long  distances,  as  in  typhoid  fever.  Again,  he 
may  be  well  but  able  to  transmit  the  disease,  as  in  the 
case  of  the  typhoid  carrier.  Then,  too,  insects  may 
transmit  disease.  Finally,  we  have  a  few  diseases 
traceable  to  the  lower  animals,  as  bovine  tuberculosis, 
plague,  anthrax,  glanders,  rabies,  Malta  fever,  and 
tapeworm. 

Adequate  preventive  measures  vary  with  the  disease. 
In  some  diseases  there  are  special  preventive  measures 
only  effective  against  the  one  disease.  Smallpox  is 
prevented  by  vaccination ;  typhoid  fever  by  sanitary 
control  of  water  and  milk  and  vaccination;  rabies  by 

291 


292  HEALTH  AND  DISEASE 

muzzling  laws,  yellow  fever  by  anti-mosquito  regula- 
tions, plague  by  war  on  rats,  and  so  on.  The  venereal 
diseases  are  preventable  only  by  social  changes.  Tuber- 
culosis is  largely  a  social  disease  and  is  to  be  eliminated 
by  social  as  well  as  by  medical  efforts.  The  individual 
can  avoid  venereal  disease  through  his  personal  efforts, 
but  his  protection  against  typhoid  fever  comes  from 
the  community.  The  individual  and  the  community 
working  together  can  accomplish  much,  but  there  is 
needed  not  only  education  of  the  community  but  also 
the  education  of  the  individual. 

Obviously  it  is  impossible  and  probably  undesirable 
that  the  individual  be  responsible  for  all  the  details  of 
the  precautionary  and  the  preventive  measures  of  all 
the  communicable  diseases.  As  we  have  shown,  these 
measures  actually  vary  in  the  case  of  each  disease.  In 
some  diseases  our  knowledge  is  as  yet  so  slight  that  we 
do  not  know  the  proper  protective  measures  either  for 
the  individual  or  for  the  community.  Consequently 
the  control  of  communicable  diseases  in  civilized  coun- 
tries is  largely  given  over  to  the  community  or  to  the 
representatives  of  the  community,  who  are,  or  should 
be,  experts  in  such  matters.  Boards  of  health  are 
intrusted  by  law  with  a  varying  amount  of  authority 
in  regard  to  communicable  diseases,  but  experience 
has  shown  that  the  legal  authority  of  the  boards  of 
health  is  inoperative  in  actual  practice,  unless  sup- 
ported by  public  opinion.  The  fear  of  leprosy  is  so 
great  that  unusual  and  perhaps  unnecessary  isolation 
is  enforced.  Yet  syphilis  exacts  its  tremendous  toll 
without  isolation  or  even  the  formal  recognition  by 
the  boards  of  health  of  the  existence  of  such  a  disease. 
The  education  of  the  individual  concerning  the  com- 
municable diseases  prevents  disease  not  only  in  his 
individual  actions  but  also  in  determining  the  activity 
of  the  health  agencies.  Intelligent  public  opinion 


PREVENTION  293 

will  not  only  support  the  wise  actions  of  the  health 
officials  of  the  community,  but  will  by  the  creation  of 
proper  machinery,  the  selection  of  competent  persons 
(keeping  matters  of  health  out  of  politics),  and  the 
appropriation  of  sufficient  funds,  largely  determine  the 
activity  of  the  health  department. 

It  must  be  frankly  admitted  that  the  prevention  of 
most  communicable  diseases  is  mainly  a  matter  of 
money.  It  is  entirely  feasible  to  eradicate  hookworm 
and  malaria  from  the  United  States,  but  it  would  cost 
vast  sums  of  money.  Thus  disease  brings  in  not  only 
the  purely  medical  factor  and  the  social  factor,  but  the 
economic  factor  as  well.  In  order  that  the  individual, 
the  taxpayer,  and  citizen,  as  well  as  the  sufferer  from 
communicable  disease,  may  wisely  decide  many  of 
these  complicated  problems  involving  medicine,  eco- 
nomics, and  sociology,  he  must  have  a  reasonable 
understanding  of  the  diseases  themselves.  Too  much 
must  not  be  expected  of  a  board  of  health  which  is 
handicapped  by  the  ignorance  of  the  public.  Medical 
knowledge,  of  course,  is  considerably  in  advance  of  the 
community  application  of  this  knowedge,  but  this  is 
partly  attributable  to  the  rapid  strides  of  medical 
science  within  the  last  thirty  years.  Boards  of  health 
endeavor  to  keep  pace  with  medical  knowledge,  but 
they  must  also,  unfortunately,  keep  in  step  with  pub- 
lic opinion. 

Naturally  one  finds  varying  activity  of  boards  of 
health,  but  all  such  boards  attempt  in  some  way  to 
control  the  spread  of  the  communicable  diseases. 
The  following  list  of  reportable  diseases,  published  by 
the  Massachusetts  State  Board  of  Health,  is  typical 
of  the  attitude  of  health  boards  in  general.  This  list 
makes  one  definite  and  purposeful  omission  in  that  it 
does  not  include  venereal  diseases,  the  omission  being 
due  to  so-called  public  prejudice.  The  second  column 


294 


HEALTH  AND  DISEASE 


lists  the  presumable  method  of  transmission  of  the 
diseases. 


Actinomycosis  Contact 

Anterior  poliomyelitis  (in- 
fantile paralysis) 

Anthrax 

Asiatic  cholera 

Cerebro-spinal-meningitis 

Chicken  pox 

Diphtheria 

Dog-bite  (requiring  anti- 
rabic  treatment) 

Dysentery 

a.  Amebic 

b.  Bacillary 
German  measles 
Glanders 

Hookworm 

Infectious  disease  of  the  eye 
a.  Ophthalmia      neona- 

torum 

6.  Suppurative      conjunc- 
tivitis 

c.  Trachoma 
Leprosy 
Malaria 
Measles 
Mumps 
Pellagra 

Plague 
Rabies 
Scarlet  fever 


Contact 

Ingestion 

Air  borne  (droplet) 

Air  borne  (droplet) 

Air  borne  (droplet) 

Contact 
Ingestion 

Air  borne  (droplet) 
Contact    and     air 

(droplet) 
Contact 


Contact 


borne 


Insect 

Air  borne  (droplet) 
Air  borne  (droplet) 
Probably  metabolic  and 

not  communicable 
Insect  and  air  borne 
Contact 
Air  borne   (droplet),  also 

ingestion 


RESULTS  AND  SEQUELAE  295 

Septic  sore  throat  Air  borne   (droplet),  also 

ingestion 

Smallpox  Air  borne  (droplet) 

Tetanus  Contact 

Trichiniasis  Ingestion 

Tuberculosis  (all  forms)          Air    borne,    ingestion, 

rarely  contact 

Typhoid  fever  Ingestion 

Typhus  fever  Insect 

Whooping  cough  Air  borne  (droplet) 

Yellow  fever  Insect 

Results  and  Sequelae  of  Communicable  Diseases 

The  communicable  diseases  are  more  important 
than  merely  causing  temporary  illness  or  death,  for 
many  times  their  after  effects  are  much  more  important 
than  the  actual  disease.  Such  after  effects  are,  roughly, 
two-fold :  general  and  specific.  It  is  well  known  that 
illness,  especially  when  associated  with  fever,  is  weaken- 
ing. A  prolonged  fever  or  a  serious  illness,  in  all 
probability,  like  hard  and  unusual  use  of  a  machine, 
causes  a  certain,  but  varying,  amount  of  deterioration. 
The  human  machine  automatically  takes  care  of  the 
wear  and  tear  of  everyday  life.  But  this  is  by  no 
means  complete  for  we  have  old  age  which,  in  reality, 
begins  at  birth,  or  even  before,  to  manifest  itself. 
Old  age  and  hardening  of  the  arteries  or  arterio-sclero- 
sis  are  practically  synonymous.  It  is  probable  that 
the  communicable  diseases,  particularly  those  with 
prolonged  fevers  or  any  other  exhausting  symptom, 
play  an  important  role  in  inaugurating  prematurely 
the  manifestations  of  old  age  and  arterio-sclerosis. 
The  communicable  diseases  represent  only  one  of  the 
factors  which  determine  premature  age,  for  heredity,  the 
general  habits  of  life,  and  other  poisons,  all  have  their 


296  HEALTH  AND  DISEASE 

share.  One  communicable  disease,  syphilis,  notoriously 
hastens  the  aging  process,  but  this  action  is  probably 
largely  a  local  effect  on  the  heart  and  blood  vessels. 

Certain  of  the  communicable  diseases  have  specific 
effects  in  addition  to  the  general  effects.  In  tuber- 
culosis, for  example,  a  person  who  has  had  trouble 
with  his  lungs,  if  he  gets  well,  will  always  have  scars 
in  his  lungs.  Most  of  the  communicable  diseases, 
however,  do  not  tend  to  destroy  the  tissue  so  as  to 
leave  a  scar,  and  the  most  careful  examination  after 
death  will  not  show  from  what  communicable  diseases 
the  person  suffered.  During  typhoid  fever  there  may 
be  a  mild  infection  of  the  gall  bladder  and  this  dis- 
turbance is  the  most  common  single  cause  of  gall- 
stones. Such  gallstones  may  not  develop  or,  at  any 
rate,  may  not  cause  symptoms  until  many  years  after 
the  typhoid  fever. 

But  there  are  sequelae  to  the  communicable  dis- 
eases, which  are  often  apparently  remote  in  time. 
Such  sequelae  are  particularly  noticeable  in  damage 
to  the  heart  and  kidneys.  Valvular  disease  of  the 
heart,  nearly  always  in  people  up  to  fifty  and  often 
in  people  over  fifty,  can  be  traced  back  to  some  in- 
fection, perhaps  many  years  before  and  generally 
apparently  trifling.  The  infection  may  be  syphilis, 
but  more  probably  it  is  caused  by  one  of  the  group  of 
diseases  due  to  the  micrococci.  After  an  epidemic  of 
tonsillitis,  for  example,  a  certain  proportion  of  cases 
will  have  permanent  damage  to  the  heart.  The  germs 
get  into  the  body,  settle  on  a  valve  of  the  heart  and 
cause  a  deformity  of  the  valve.  What  happens  after 
tonsillitis  may  happen  after  any  other  of  the  infectious 
diseases.  It  is  easy  to  say  that  such  diseases  as  ton- 
sillitis and  gonorrhea  are  trivial,  but  the  victim  of  one 
of  these  diseases  may  be  incapacitated  from  heart 
disease  as  a  result  of  these  ailments. 


RESULTS  AND  SEQUELS  297 

Diseases  of  the  kidneys  also  follow  certain  of  the 
communicable  diseases.  Kidney  disease  (Bright's 
disease),  especially  in  young  people,  is  particularly  apt 
to  follow  scarlet  fever. 

Heart  disease  and  Bright's  disease  are  definitely  t 
on  the  increase  and,  together,  are  the  cause  of  one  out  \ 
of  every  five  deaths.  There  are,  of  course,  various 
forms  of  such  disease  and  they  are  often  only  the  ex- 
pression of  aging  and  the  wear  and  tear  on  the 
human  body,  but  in  middle  life  and  in  young  adult 
life  they  are  usually  traceable  to  some  infectious 
disease.  The  prevention  of  heart  and  kidney  dis- 
ease, therefore,  means  the  prevention  of  communi- 
cable diseases.  The  toll  of  the  communicable  diseases 
is  not  found  only  in  immediate  mortality  or  immediate 
disability  tables,  but  also  in  the  deaths  and  disabilities 
of  their  sequelae. 

It  will  be  noted  that  the  discussion  of  the  communi- 
cable diseases  has  not  included  all  the  diseases  of 
bacterial  origin.  In  general,  inflammation  is  caused 
by  bacteria.  These  bacteria  must  be  derived  from 
somewhere,  so,  in  a  sense,  all  bacterial  inflammations 
are  communicable.  The  inflammatory  damage  of  the 
heart  and  kidneys,  bacterial  in  origin,  begins  with  some 
infectious  disease  and  often  continues  in  the  heart  and 
kidney  long  after  the  infectious  disease  has  apparently 
disappeared.  In  a  similar  fashion  most  structures  of 
the  body  are  subject  to  inflammation.  The  source  of 
the  bacteria  which  causes  the  inflammation  may  be, 
and  often  is,  obscure.  We  have  in  our  intestinal  tract, 
for  example,  many  bacteria  that  are  harmless  so  long 
as  they  do  not  leave  the  tract.  But  under  special 
conditions  of  the  intestines,  as  an  injury,  or  of  diet, 
or  of  the  bacteria  themselves,  the  intestinal  tract  may 
furnish  to  any  part  of  the  body  the  bacteria  which  may 
inflame  any  structure. 


298  HEALTH  AND  DISEASE 

Appendicitis  is  caused  by  bacterial  action.  Our 
present  knowledge  does  not  permit  us  to  apportion  the 
various  factors  which  bring  about  this  disease.  A 
variety  of  bacteria  may  be  the  cause,  but  just  what 
factor  or  factors  allow  the  bacteria  to  inflame  the 
appendix  is  at  present  unknown.  It  seems  reasonable 
to  assume  that  a  proper  diet  and  a  normally  acting 
intestinal  tract  do  much  to  prevent  appendicitis,  al- 
though we  must  confess  that  the  disease  is  in  no  way 
preventable. 

Another  source  which  furnishes  bacteria  for  the 
inflammation  of  various  structures  is  the  whole  region 
of  the  nose,  mouth,  and  throat.  We  are  beginning  to 
appreciate  that  bacteria  about  diseased  teeth,  damaged 
tonsils,  and  abnormal  sinuses  frequently  invade  distant 
parts  of  the  body  and  cause  inflammation  of  these 
structures.  This  seems  to  be  especially  true  of  joints. 
The  prevention  means  the  correction  of  abnormalities 
which  favor  the  entrance  and  development  of  the 
bacteria  in  the  original  focus.  In  a  similar  way  any 
inflammatory  focus  in  the  body  may  serve  as  the 
source  from  which  bacterial  inflammation  of  a  distant 
organ  may  arise. 

Certain  forms  of  so-called  "  rheumatism  "  illustrate 
how  a  variety  of  bacteria  may  inflame  one  of  the  struc- 
tures of  the  body,  namely,  the  joints.  *'  Rheumatism  " 
is  a  difficult  disease  to  define.  From  a  medical  stand- 
point rheumatism  may  be  divided  into  two  large  groups 
classified  according  to  the  causes.  One  type  is  due 
to  bacteria  or  its  poisons,  the  so-called  infectious  form 
of  rheumatism.  Another  type  is  due  to  chemical 
changes  in  the  body,  metabolic  rheumatism.  The 
latter  form  of  the  disease  is  familiar  because  it  fre- 
quently occurs  in  old  people  who  have  deposits  around 
their  joints.  The  usual  form  of  rheumatism  is  that 
associated  with  bacteria,  which  is  found  more  fre- 


RESULTS  AND  SEQUELAE  299 

quently  and  more  severely  in  the  changeable  climates 
of  the  Temperate  zone.  The  disease  has  been  known 
as  long  as  we  have  any  records  in  the  form  of  literature. 

Rheumatic  fever  is  a  fairly  definite  disease  of  varying 
severity.  Definite  germs  have  been  isolated  and  de- 
scribed, which  have  been  associated  with  particular 
epidemics  of  rheumatic  fever.  There  is  a  good  deal 
of  evidence  to  show  that  there  are  waves  of  rheumatic 
fever  and  in  addition  the  character  of  the  disease 
alters  in  different  outbreaks.  Closely  allied  with 
epidemic  occurrences  is  the  possibility  of  spread  by 
contagion  and  some  remarkable  examples  of  this  have 
been  recorded.  The  classical  form  of  rheumatic  fever 
is  associated  with  a  definite  micrococcus. 

Rheumatism,  or,  better,  arthritis,  frequently  follows 
tonsillitis.  In  this  case  the  micro-organisms  which 
cause  the  tonsillitis  secure  entrance  to  the  blood  and 
infect  the  joints.  At  the  same  time  the  bacteria  may 
go  to  the  valves  of  the  heart.  Twenty-five  per  cent 
of  the  people  who  have  rheumatic  fever  or  an  in- 
flammation of  more  than  one  joint  with  fever  eventu- 
ally manifest  some  damage  to  the  heart  valves.  The 
same  condition  of  affairs  may  follow  an  attack  of 
gonorrhea.  Scarlet  fever,  pneumonia,  and  infected 
teeth  and  tonsils  may  also  cause  rheumatism.  In 
every  case  it  is  an  evidence  that  the  disease  is  no  longer 
local,  but  that  the  germs  have  secured  an  entrance  into 
the  blood  and  attacked  the  joints  of  the  patients.  It 
should  be  remembered  that  rheumatism,  by  and  large, 
is  an  evidence  that  the  defenses  of  the  body  have  broken 
down  and  that  the  disease  is  no  longer  local. 

The  seriousness  of  the  acute  form  of  rheumatism  is 
not  at  all  dependent  on  the  temporary  involvement  of 
the  joints.  It  derives  its  serious  aspect  from  the  fact 
that  it  represents  a  general  infection  and  the  liability 
to  heart  disease.  All  these  conditions  must  have  a 


300  HEALTH  AND  DISEASE 

'  point  of  entrance.  The  particular  point  of  entrance 
for  rheumatic  fever  is  usually  the  nose  and  throat, 
particularly  the  tonsils.  If  it  were  not  for  diseased 
tonsils,  the  cases  of  rheumatic  fever  and  the  subsequent 
devastation  from  heart  trouble  and  kidney  trouble 
would  probably  be  few. 


CHAPTER  XVIII 
CANCER 

CANCER  presents  one  of  the  most  serious  problems  of 
disease,  for  not  only  does  it  cause  a  considerable  pro- 
portion of  the  deaths  —  from  five  to  ten  per  cent  — 
but  there  seems  to  be  no  doubt  that  the  disease  is  in- 
creasing rapidly.  In  1915  in  the  registration  area  of 
the  United  States  there  were  54,584  deaths  from  cancer 
and  other  malignant  tumors,  and,  if  the  whole  country 
had  been  included,  the  figures  would  probably  show 
about  80,000  deaths  from  this  disease.  But  the  rapid 
increase  of  the  death  rate  from  cancer  is  the  most 
alarming  feature.  The  death  rate  has  risen  from 
sixty-three  per  100,000  in  1900  to  81.1  in  1915.  In 
Massachusetts  in  1871  the  recorded  cancer  death  rate 
was  36.9  per  100,000  of  population;  in  1881,  52.3; 
in  1891,  60.9 ;  in  1901,  73.1,  and  in  1911,  92.6.  Statis- 
tics seem  to  prove  that  throughout  the  world  cancer 
annually  kills  some  500,000  people  and  that  the  disease 
is  markedly  on  the  increase  in  all  civilized  countries. 

In  spite  of  the  great  efforts  which  have  been  made 
in  the  study  of  cancer,  we  know  comparatively  little 
about  it.  We  actually  have  no  idea  of  the  cause  of 
cancer,  and  we  have,  therefore,  little  idea  of  how  to 
check  the  growth  of  its  mortality.  Many  theories 
have  been  set  forth  as  to  the  cause.  The  available 
evidence  seems  to  indicate  that  cancer  and  tumor  are 
not  caused  by  bacteria.  There  is  some  evidence 
which  tends  to  show  that  errors  in  nutrition  may 

301 


302  HEALTH  AND  DISEASE 

be  a  contributory  cause  as  may  be  various  irritations. 
It  is  not  believed  that  the  disease  is  hereditary. 
Cancer  is  probably  a  disease  associated  with  the 
general  tendency  of  retrogression  in  the  body;  that 
it  is  a  part  and  parcel  of  old  age,  for  cancer  is 
essentially  and  mainly  a  disease  of  late  adult  life 
and  old  age. 

Cancer  occurs  in  all  walks  of  life  and  in  all  countries. 
It  causes  a  slightly  larger  death  rate  among  females 
than  among  males.  Savage  tribes  seem  to  be  some- 
what immune  and  so  cancer  has  been  attributed  to  the 
evils  of  civilization.  But  this  is  simply  a  matter  of 
opinion,  for,  of  course,  we  have  no  reliable  statistics 
on  this  matter.  Malignant  tumors,  often  closely 
resembling  human  tumors,  occur  in  many  of  the  lower 
animals.  Spontaneous  tumors  of  mice  are  rather 
common. 

There  is  no  medical  treatment  for  cancer.  The 
simplest  and  best  thing  to  do  is  to  have  the  growth 
removed  by  the  knife,  although  the  X-ray  and  radium 
may  also  be  used  to  accomplish  the  same  end.  Probably 
the  combination  of  the  knife  and  the  subsequent  use 
of  the  X-ray  is  the  best  method.  The  statement  often 
advertised  by  unscrupulous  quacks  that  all  cancers  can 
be  removed  by  the  X-ray  and  radium  is  a  cruel  untruth, 
for  they  only  destroy  cancers  which  are  situated 
favorably.  If  the  growth  is  a  large  one,  the  X-ray 
and  radium  would  have  to  be  used  to  such  an  extent 
as  to  destroy  the  surrounding  tissues  and  life. 

Education  of  the  public  as  to  the  dangers  of  cancer 
and  the  best  methods  to  pursue  in  its  eradication  seems 
to  be  the  most  hopeful  method  of  decreasing  the  in- 
creasing mortality  from  the  disease.  It  should  be 
insisted  that  cancer,  if  removed  early,  is  a  curable 
disease,  but,  if  neglected,  it  is  invariably  fatal.  All 
chronic  irritations  should  be  avoided  and,  if  any  wart 


CANCER  303 

or  sore  occurs  spontaneously,  as  on  the  lip,  after  the  age 
of  forty-five,  it  is  ordinarily  cancer. 

The  following  directions  to  the  public,  issued  by 
an  English  city,  are  so  excellent  as  to  be  worthy  of 
imitation  elsewhere : 


Instructions  on  Prevention  of  Cancer 

1.  Cancer,  in  its  early  and  curable  stage,  gives  rise 
to  no  pain  or  symptom  of  ill-health  whatever. 

2.  Nevertheless,  in  its   commonest    situations,    the 
signs  of  it  in  its  early  stage  are  conspicuously  manifest. 

3.  In  case  of  any  swelling  occurring  in  the  breast  of 
a  woman  after  forty  years  of  age,  a  medical  man  should 
at  once  be  consulted.     A  large  proportion  of   such 
swellings  are  cancer. 

4.  Any  bleeding,  however    trivial,    occurring    after 
the  change  of  life  means  almost  invariably  cancer,  and 
cancer  which  is  then  curable.     If  neglected  till  pain 
occurs,  it  means  cancer  which  is  almost  incurable. 

5.  Any  irregular  bleeding  occurring  at  the  change 
of  life  should  invariably  be  submitted  to  a  doctor's 
investigation.     It  is  not  the  natural  method  of  the 
onset  of  the  change  of  life,  and  in  a  large  number  of 
cases  means  commencing  cancer. 

6.  Any  wart  or  sore  occurring  spontaneously  on  the 
lower  lip  in  a  man  over  45  years  of  age  is  almost  cer- 
tainly cancer.     If  removed  at  once  the  cure  is  certain, 
if  neglected  the  result  is  inevitably  fatal. 

7.  Any  sore  or  swelling  occurring  on  the  tongue  or 
inside  of  the  mouth  in  a  man  after  45  years  of  age 
should  be  submitted  to  investigation  without  a  mo- 
ment's delay,  and  the  decision  at  once  arrived  at  by 
an  expert  microscopical  examination  whether  it  is  can- 
cer or  not.     A  very  large  proportion  of  such  sores  or 
swellings  occurring  at  this  time  of  life  are  cancer,  and 


304  HEALTH  AND  DISEASE 

if  neglected  for  only  a  few  weeks  the  result  is  almost 
inevitably  fatal.  If  removed  at  once  the  prospect  of 
cure  is  good. 

8.  Any  bleeding  occurring  from  the  bowel   after 
45  years  of  age,  commonly  supposed  by  the  public  to 
be  **  piles",  should  be  submitted  to  investigation  at 
once.     A  large  proportion  of  such  cases  are  cancer, 
which  at  this  stage  is  perfectly  curable. 

9.  When  warts,  moles,  or  other  growths  on  the  skin 
are  exposed  to  constant  irritation,  they  should  be  im- 
mediately   removed.     A    large    number    of    them,    if 
neglected,  terminate  in  cancer. 

10.  Avoid  irritation  of  the  tongue  and  cheeks  by 
broken  jagged  teeth,  and  of  the  lower  lip  by  clay  pipes. 
Many  of  these  irritations,  if  neglected,  terminate  in 
cancer. 

11.  Although  there  is  no  evidence  that  cancer  is 
communicable    under    ordinary    circumstances    it    is 
desirable  that  rooms  occupied  by  a  person  suffering 
from  cancer  should  be  cleaned  and  disinfected  from 
time  to  time. 


CHAPTER  XIX 

MILK 

MILK  is  the  most  liable  of  all  the  foods  to  convey 
disease,  for  several  reasons.  Milk  is  an  excellent 
medium  for  the  growth  of  bacteria.  It  is  the  most 
difficult  of  the  food-stuffs  to  obtain,  handle,  and  de- 
liver in  a  clean,  fresh,  and  satisfactory  condition. 
Milk  decomposes  rapidly,  and,  finally,  it  is  the  only 
important  article  of  diet  which  is  consumed  in  the 
raw  state.  As  the  amount  of  milk  consumed  as  food 
is  enormous,  the  problem  of  safeguarding  the  supply 
is  one  of  the  utmost  importance. 

Milk  itself  is  not  dangerous.  Even  the  presence  of 
bacteria  does  not  make  it  dangerous.  It  is  the  presence 
of  disease-causing  bacteria  in  the  milk  which  is  dan- 
gerous. Bacteria-free  milk  is  a  practical  impossibility. 
The  health  authorities  merely  specify  the  maximum 
number  of  bacteria  that  milk  may  contain.  In  Massa- 
chusetts one  cc.  of  milk  may  not  contain  more  than 
500,000  bacteria,  while  New  York  permits  1,000,000 
per  cc.  It  follows  that  these  requirements  based  on 
bacterial  counts  are  founded  on  the  doctrine  of  chances. 
When  there  are  few  bacteria  in  milk,  there  is  much  less 
likelihood  of  some  of  these  bacteria  being  the  disease- 
bearing  types  than  when  there  are  many  bacteria  which 
are  probably  introduced  by  gross  contamination. 
This  theory  works  well  in  practice. 

It  is  evident  that  bacteria  can  get  into  milk  from  two 
sources,  one  from  the  milk-giving  animal ;  the  other 

305 


306  HEALTH  AND  DISEASE 

from  outside.  The  most  important  bacterium  which 
comes  from  the  cow  is  the  tubercle  bacillus.  The  im- 
portance of  bovine  tubercle  bacilli  in  the  causation  of 
certain  forms  of  tuberculosis  has  already  been  sug- 
gested. The  presence  of  such  bacilli  in  milk  is  ex- 
tremely common  and  it  is  estimated  that  ten  per  cent 
of  uninspected  milk  contains  tubercle  bacilli.  As  a 
rule  tubercle  bacilli  are  only  present  in  the  milk  when 
there  is  tuberculous  disease  of  the  udder,  a  diseased 
condition  of  the  cow  which  can  usually  be  detected 
by  superficial  examination  of  those  parts.  The  tuber- 
culin test,  while  not  infallible,  is  of  great  value  in  re- 
vealing any  tuberculosis  in  the  cow.  Any  cow  which 
shows  positive  signs  of  tuberculosis  should  be  eliminated 
from  the  herd,  for  the  danger  from  such  a  cow  far  out- 
weighs any  economic  considerations.  Such  a  cow  will 
spread  tuberculosis  among  the  other  cows  and  eventu- 
ally from  some  of  the  cows  tubercle  bacilli  will  be 
present  in  the  milk. 

Cows  may  also  be  afflicted  with  inflammation  of 
the  udder,  the  most  common  being  an  inflammation 
caused  by  the  streptococcus,  the  same  organism  which 
causes  septic  sore  throat.  Epidemics  of  septic  sore 
throat  have  been  traced  to  milk  from  a  cow  with  in- 
flammation of  the  udder,  although  the  majority  of 
milk-borne  epidemics  of  septic  sore  throat  can  be 
traced  to  milk  contaminated  from  human  sources. 
Diseases  of  the  udder  can  be  easily  detected  by  in- 
spection and  can  be  controlled  by  examination  of  the 
milk  itself.  The  presence  of  pus-cells  in  the  milk, 
together  with  a  high  bacterial  count,  indicates  udder 
inflammation  of  the  cow. 

Mention  should  be  made  of  the  transfer  of  Malta 
fever  to  human  beings  by  drinking  milk  from  goats  with 
the  same  disease,  and  also  of  the  transfer  of  milk  sick- 
ness, "  slows  "  or  "  trembles",  and  of  foot  and  mouth 


MILK  307 

disease  by  milk  from  cows  with  these  diseases.  All 
these  diseases  are  preventable  by  the  competent  in- 
spection of  dairy  herds. 

The  milk  of  cows  and,  likewise,  the  milk  of  human 
beings  is  affected  by  the  food  and  so  may  affect 
those  taking  the  milk.  Reasonable  care  should  be 
taken  where  cows  graze.  The  cows  which  furnish 
the  highest  grade  of  milk  for  infants  are  not  per- 
mitted to  graze  at  large  but  are  wisely  fed  on  carefully 
selected  fodder. 

Despite  these  possible  dangers  arising  from  the  animal 
giving  the  milk,  experience  has  shown  that  most  of  the 
danger  comes  after  the  milk  has  left  the  animal.  There 
is  little  danger  from  milk  taken  on  the  so-called  "  short 
haul."  Thus  the  breast-fed  baby  and  the  suckling 
calf  usually  flourish,  provided  the  mother  is  healthy. 
But  most  of  our  milk  is  consumed  after  a  long  haul. 
The  danger  of  the  contamination  of  milk  is  obviously 
proportional  to  the  length  of  the  haul,  if  one  includes 
the  length  of  time  and  the  amount  of  handling  as  well 
as  the  distance.  Milk  may  be  contaminated  at  any 
point  from  the  cow  to  the  consumer. 

Dirt  from  the  cow  may  fall  into  the  milk ;  the  hands 
of  the  milker  may  be  none  too  clean ;  the  pail  may  be 
dirty,  and  the  milk  may  be  taken  in  an  uncovered 
vessel  on  a  long  and  circuitous  route  through  a  dirty 
barnyard.  The  barnyard  flavor  and  smell  of  milk  so 
highly  regarded  by  some  people  is  due  to  barnyard  dirt 
in  the  milk.  From  the  barn  milk  may  go  on  a  long 
journey,  perhaps  with  many  changes  of  containers, 
where  it  is  exposed  to  air  and  dirt.  As  the  milk  is 
sold,  it  may  be  exposed  again  and,  finally,  it  may  be 
contaminated  during  serving.  Thus  the  possibility 
of  contamination  is  enormous.  The  milk  will  inevitably 
contain  some  bacteria.  But  while  milk  furnishes  such 
an  excellent  medium  for  growth  of  bacteria,  the  growth 


308  HEALTH  AND  DISEASE 

can  be  checked  by  keeping  it  cool  at  all  times.  This 
means  a  temperature  of  50°  F.,  or  lower,  for  above  this 
temperature  bacteria  will  grow  rapidly.  The  souring 
of  milk  depends  on  the  activity  of  bacteria,  but  the 
usual  bacteria  which  sour  milk  are  harmless  and  their 
rapid  growth  is  prevented  by  cold  just  as  the  growth 
of  the  harmful  bacteria  which  may  or  may  not  be 
present  in  the  milk. 

All  the  diseases  which  are  transmitted  by  water 
may  be  transmitted  by  milk  and  many  others  in  ad- 
dition. Epidemics  of  typhoid  fever  and  cholera  have 
been  traced  to  milk.  Diphtheria  and  scarlet  fever, 
although  usually  air-borne,  are  sometimes  transmitted 
by  milk.  Within  the  past  few  years  a  number  of 
epidemics  of  septic  sore  throat  have  been  transmitted 
by  milk.  While  this  may  have  its  origin  in  the  in- 
flammation of  the  cow's  udder,  it  is  more  often  caused 
by  an  infection  from  the  person  who  handles  the  milk. 
Milk-borne  epidemics  are  usually  of  sudden  onset  and 
affect  all  susceptible  persons  who  drink  the  milk. 
Milk  is  frequently  infected  on  a  small  scale.  Thus 
one  can  trace  to  milk  many  of  the  intestinal  disturb- 
ances of  infancy  and  childhood.  Milk  is  almost  the 
exclusive  food  of  infants  and  infant  mortality  is  largely 
dependent  on  the  milk  supply.  It  is  well  known  that 
intestinal  disturbances  of  childhood  (cholera  infantum, 
summer  diarrhea,  etc.)  are  much  more  common  in 
summer  when  it  is  difficult  to  keep  milk  cold  and  thus 
prevent  the  growth  of  bacteria. 

In  most  of  the  warm  European  countries  milk  is 
only  used  as  food  for  infants,  due  to  the  fact  that  the 
people  use  little  ice  and  so  have  difficulty  in  keeping 
the  milk.  Their  experiences  with  diseases  from  milk 
have  caused  them  to  restrict  the  use  of  milk  for  food 
to  infants  and  to  immediate  consumption.  Milk  is 
used  in  the  United  States  as  a  food  for  adults  far  more 


MILK  309 

than  in  any  other  country  of  the  same  climate  and 
density  of  population. 

Since  it  is  often  impossible  to  classify  milk  as  good 
or  bad  without  examinations  which  are  not  finished 
until  after  the  milk  is  consumed,  another  classification 
is  widely  used. 

_  Certified  milk  means  an  excellent  milk  which  is  pro- 
duced under  the  very  best  of  conditions.  It  means 
that  all  reasonable  precautions  against  contamination 
have  been  taken  all  along  the  line  of  production  and 
distribution.  However,  these  precautions  are  only 
those  which  are  demanded  by  common  sense.  Instead 
of  having  a  dirty  barn,  it  is  necessary  to  have  a  clean 
barn;  the  cows  must  be  kept  clean  and  the  udders 
washed  carefully.  The  cows  are  frequently  inspected 
and  tuberculin  tested.  Then  the  man  who  milks  the 
cow  must  have  clean  hands  and  clean  clothes  and 
cleanly  habits.  The  milk  is  taken  into  pails  which 
have  been  not  merely  washed  but  boiled.  The  milk 
is  then  kept  in  sterile  conditions  at  a  temperature 
under  50°  F.  If  all  these  precautions  are  taken,  milk 
may  be  produced  which  contains  less  than  10,000 
bacteria  per  cc.  Of  course  it  is  not  entirely  the  actual 
number  of  bacteria  which  concerns  us,  but  the  type. 
This  milk  is  naturally  expensive  to  produce  and  is  used 
for  babies  and  in  hospitals. 

The  second  form  of  milk  is  inspected  milk.  This 
should  contain  not  more  than  100,000  bacteria  per  cc. 
Inspected  milk  means  that  the  cows  are  healthy  and 
have  been  reasonably  inspected,  that  the  milk  is  pro- 
duced under  reasonably  clean  conditions,  and  that 
reasonable  precautions  have  been  taken  to  keep  the 
milk  clean  and  cold  from  the  cow  to  the  consumer.  All 
milk  should  be  inspected. 

The  third  form  is  market  milk.  This  grade  of  milk 
does  not  come  from  inspected  sources  and  nobody 


310  HEALTH  AND  DISEASE 

knows  the  condition  of  the  cattle  or  the  barns  in  which 
it  is  produced.  Most  of  the  milk  which  is  sold  in  the 
large  cities  may  be  so  classified.  The  one  check  which 
we  have  on  such  milk  is  the  requirement  as  to  the  num- 
ber of  bacteria.  All  milk  of  this  grade  should  be 
pasteurized. 

Pasteurization  of  milk  consists  in  heating  it  to  such 
a  temperature  that  it  will  destroy  most  forms  of  bac- 
terial life  (60°  C.  or  140°  F.).  This  amount  of  heat 
continued  from  twenty  minutes  to  half  an  hour  will 
kill  all  the  pathogenic  bacteria  but  not  spores.  Boiling 
milk  is  even  more  effective  but  it  affects  the  taste  and 
probably  the  food  value  to  some  extent,  while  pasteuri- 
zation does  not. 

Home  pasteurization  is  more  difficult  than  it  seems 
at  first  sight,  especially  on  a  small  scale.  On  the  other 
hand,  pasteurization  on  a  large  commercial  scale  is 
relatively  simple.  It  is  also  desirable  that  pasteuriza- 
tion should  take  place  when  there  is  to  be  as  little  sub- 
sequent handling  of  the  milk  as  possible.  Pasteuriza- 
tion of  milk  is  recommended  merely  as  a  reasonable 
and  harmless  method  of  safeguarding  milk  of  doubtful 
quality. 

Preservation  of  Milk.  Numerous  attempts  to  pre- 
serve milk  have  been  made,  but,  at  the  present  time, 
no  completely  satisfactory  product  has  appeared. 
Dried  or  evaporated  milk  seems  to  be  promising,  but 
in  all  these  substitutes  it  must  be  remembered  that  no 
substitute  can  ever  be  any  better  than  the  milk  from 
which  it  is  made.  Children  fed  on  prepared  products 
rarely  thrive,  presumably  due  to  the  loss  of  vitamins 
in  the  preparation.  Nevertheless  honestly-made  con- 
densed, evaporated,  and  other  forms  of  preserved  milk 
may  be  suitable  for  a  portion  of  an  adult's  diet. 

Such  preservatives  as  borax,  formalin,  and  the  like 
are  now  practically  excluded  by  law.  Not  only  are 


MILK  311 

many  of  these  substances  harmful  in  themselves,  but 
they  also  usually  cause  harmful  combinations  with 
milk.  If  milk  is  obtained  under  favorable  conditions 
and  kept  cold  at  a  temperature  which  inhibits  the 
growth  of  bacteria,  the  milk  will  keep  for  a  number  of 
days.  Ocean  liners  are  supplied  with  such  milk  which 
lasts  throughout  a  voyage  of  ordinary  length. 

Sour  milk,  provided  that  it  is  soured  by  one  of  the 
non-pathogenic  milk-souring  group  of  bacteria,  is  not 
at  all  harmful.  During  recent  years  sour  milk  and 
buttermilk  have  been  generally  recommended  by 
physicians.  The  enthusiasm  for  these  products  has 
been  carried  so  far  that  tablets  of  lactic  acid  bacilli 
have  been  prepared  for  consumption  after  meals.  All 
that  these  tablets  contain  are  millions  of  bacteria 
pressed  into  a  tablet  and  it  is  supposed  that  these 
bacteria  cause  some  beneficial  change  in  the  intestinal 
tract.  There  is  no  question  that  lactic  acid  bacilli 
have  a  laxative  effect,  but  they  have  no  wonderful 
or  extraordinary  power. 

Adulteration  of  Milk.  Adulteration  of  milk  means 
the  addition  of  certain  substances  which  may  or  may 
not  be  harmful.  The  substances  usually  added  are 
water,  preservatives,  or  some  white  substance  intended 
to  convey  the  impression  of  richness.  Before  adultera- 
tion, the  milk  is  generally  deprived  of  its  cream,  or 
skimmed,  so  that  the  adulteration  is  more  a  question 
of  honesty  than  of  health.  Adulteration  is,  as  a  rule, 
easily  detected  by  examination,  for  the  law  requires  a 
certain  amount  of  solids  and  of  butter  fat. 

In  the  effort  to  have  better  milk  there  has  always 
been  more  or  less  of  a  quarrel  with  the  farmers.  The 
latter  tend  to  assert  that  they  know  how  to  produce 
milk  and  resent  interference.  In  addition,  many 
times,  the  farmers  have  been  rather  badly  treated  by 
the  middlemen.  On  the  other  hand,  it  is  true  that 


312  HEALTH  AND  DISEASE 

some  farmers,  who  produce  milk  for  the  distant  im- 
personal consumer,  may  not  exercise  the  care  of  cows, 
hands,  barns,  and  cans,  which  is  necessary  for  the  safe 
consumption  of  milk  many  hours  later,  miles  away. 
Unsafe  milk  is  not  attributable  to  the  farmers  any  more 
than  to  any  other  handler  from  the  cow  to  the  con- 
sumer. But  in  order  to  get  safe  milk  it  is  necessary 
to  be  certain  of  the  source  of  the  milk  by  competent 
inspection  of  the  dairy  herds.  There  must  be  assur- 
ance of  the  cleanliness  of  all  the  conditions  of  producing, 
transportation,  selling,  and  serving  of  milk  by  adequate 
inspection. 

A  New  England  city  has  recently  suffered  from  an 
epidemic  of  typhoid  fever  which  was  traced  to  the 
milk  from  a  farmer  who  "  took  no  stock  in  pasteuriza- 
tion." His  inability  to  appreciate  the  fundamentals 
of  properly  producing  milk  nearly  cost  him  his  life  — 
he  contracted  the  disease  himself  —  and  did  cause 
disease  to  a  considerable  number  of  people. 

In  addition  to  the  inspection  of  the  source  and  the 
methods  of  handling  milk,  all  milk  should  be  subjected 
to  periodic  examination  at  times  of  consumption. 
This  examination,  which  is  easily  carried  out  by  an 
adequate  laboratory,  will  serve  to  check  up  the  in- 
spection. Examination  will  readily  disclose  any  faults. 
Lastly,  unless  milk  after  inspection  shows  constantly 
a  low  bacterial  count  under  50,000,  pasteurization  is 
probably  desirable. 

Clean,  safe  milk  is  more  expensive  to  produce  than 
doubtful  milk.  For  example,  milk  from  diseased  cows 
must  not  be  used  and  represents  a  loss.  It  means 
time,  labor,  and  some  equipment  to  sterilize  cans  and 
other  containers  of  milk,  rather  than  to  trust  that  the 
other  fellow  has  washed  them.  The  transportation 
of  milk  under  proper  conditions  means  rapid  travel 
and  ice.  The  substitution  of  separate  milk  cans  and 


MILK  313 

bottles,  which  avoids  much  handling,  is  more  expen- 
sive than  large  cans  and  the  old  dip-tank  with  the 
measure,  all  of  which  were  exposed  to  contamination 
and  usually  needed  washing.  Cleanliness,  perhaps, 
costs  more  in  terms  of  intelligence  than  in  terms  of 
money,  but  clean,  safe  milk  means  a  saving  of  doctors' 
bills  to  the  family  and  of  loss  to  the  community. 

Everything  which  has  been  said  about  milk  applies 
as  well  to  cream  and  butter,  for  they  are  definitely 
milk  products  and  carry  the  same  risks  as  milk  itself. 
In  point  of  fact  the  cream  contains  more  bacteria  than 
the  whole  milk.  More  samples  of  butter  contain  tu- 
bercle bacilli  than  do  milk. 

Milk  and  Infant  Mortality.  Infants  —  children 
under  one  year  —  are  largely  dependent  on  milk  and 
the  question  of  pure  milk  is,  therefore,  closely  re- 
lated to  that  of  infant  mortality.  The  infant  mor- 
tality represents  about  one-fifth  of  all  the  deaths  of 
any  nation,  an  enormous  death  rate,  larger  than 
that  from  any  single  disease.  We  can  gauge,  fairly 
accurately,  the  intelligence  and  prosperity  of  a  people 
by  its  rate  of  infant  mortality.  In  poor  families 
the  infant  mortality  is  large.  In  the  more  well- 
to-do  families  there  are  not  so  many  children  and 
such  families  are  more  successful  in  "raising  the 
children." 

Within  the  last  few  years  there  has  been  a  tremen- 
dous interest  in  infant  mortality  and  the  statistics  on 
this  matter  are  available.  Chile  has  a  general  average 
death  rate  of  31-^  per  thousand  of  population,  but  the 
infant  mortality  for  ten  years  has  averaged  330  per 
thousand  births.  The  infant  mortality  in  Australia, 
in  contrast,  is  around  seventy  per  thousand.  Scotland 
averages  109,  England  101,  Ireland  72,  and  Norway 
and  Sweden  from  76  to  85  per  thousand  births.  It  is 
surprising  to  find  that  the  usually  efficient  Prussia  has 


314  HEALTH  AND  DISEASE 

the  high  infant  mortality  of  164  per  thousand,  while 
the  average  mortality  of  infants  in  the  United  States 
is  about  140. 

There  are  three  great  causes  of  infant  mortality : 
immaturity ;  the  respiratory  diseases  —  diseases  of  the 
lungs,  such  as  pneumonia,  and  the  digestive  diseases. 
The  pneumonia  may,  however,  be  only  terminal,  — 
that  is,  a  poorly  nourished  child  contracts  pneumonia 
more  easily  and  more  easily  succumbs  to  the  disease. 
The  most  important  cause  of  infant  mortality,  however, 
is  the  digestive  diseases. 

Infants  depend  on  milk  for  food,  and  hence  for  their 
growth,  their  well  being,  and  their  resistance  to  disease. 
Statistics  show  that  the  bottle-fed  baby  has  a  much 
smaller  chance  of  survival  than  the  breast-fed  baby. 
This  is  particularly  true  in  the  summer,  when  the 
difficulty  of  keeping  milk  cold  and  of  preventing  bac- 
terial growth  is  inevitably  associated  with  digestive 
disturbances  in  infants.  The  breast-fed  baby  secures 
his  milk  without  the  attendant  dangers  which  a  bottle- 
fed  baby  must  run. 

A  brave  attempt  is  being  made  to  combat  infant 
mortality,  mainly  by  insisting  on  the  purity  of  the 
milk  supply,  but  there  are  a  number  of  other  factors 
which  enter  into  this  problem.  Many  mothers  have 
to  work  and  this  means  that  the  child  gets  insufficient 
care  and  that  the  mother  is  unable  to  nurse  her  child. 
Then,  too,  there  comes  the  problem  of  the  proper 
nourishment  of  the  mother.  If  she  is  underfed,  as 
well  as  overworked,  the  mother  cannot  produce  either 
the  proper  kind  or  a  sufficient  quantity  of  milk  for  the 
child.  Poverty,  ignorance,  and  low  standards  of 
living  are  the  fundamental  causes  of  an  excessive 
infant  mortality.  A  valuable  experiment  has  been 
instituted  in  establishing  milk  stations  in  large  cities, 
where  milk  of  known  purity  is  sold.  These  stations 


MILK  315 

are  of  the  greatest  importance  for  in  no  large  city  is 
the  milk  situation  treated  adequately. 

Many  cities  have  seen  the  establishment  of  pre- 
natal clinics.  The  object  of  such  institutions  is  to  assure 
the  child  of  as  good  a  start  in  life  as  possible  and  to 
educate  the  prospective  mother  concerning  the  man- 
agement of  infants.  Such  movements  are  associated 
with  proposed  legislation  concerning  the  employment 
of  women  during  and  just  after  pregnancy.  Many  of 
the  factors  concerned  in  the  causation  of  infant  mor- 
tality are  definitely  social  and  economic  and  the  rem- 
edies are  to  be  found  in  a  readjustment  of  our  present 
social  and  economic  systems.  But  the  factor  of  milk, 
probably  the  most  important,  directly  or  indirectly, 
can  be  easily  remedied  by  adherence  to  the  considera- 
tions which  have  been  presented  in  this  chapter. 


CHAPTER  XX 

WATER 

WATER  is  an  ever-present  and  indispensable  factor 
in  human  life.  Water  makes  up  about  seventy  per 
cent  of  the  human  body  and,  in  addition,  is  a  con- 
siderable element  in  all  foods.  Then  the  average 
person  drinks  more  or  less  water,  and  even  infants 
whether  bottle-  or  breast-fed  usually  take  some  water 
as  such.  The  human  animal  will  die  if  deprived  of 
water  for  a  few  days,  and,  furthermore,  he  demands 
water  for  the  proper  cleansing  of  his  body,  his  clothing, 
and  his  utensils.  In  addition,  the  water-carriage  sys- 
tem of  sewage  depends  on  the  use  of  enormous  amounts 
of  water,  as  do  certain  industries,  fire  service,  street 
washings,  and  similar  uses.  All  these  activities  make 
the  total  amount  of  water  demanded  by  our  modern 
standards  of  life  and  health  so  enormous  as  to  be  be- 
yond the  comprehension  of  our  ancestors.  Formerly 
a  gallon  of  water  per  person  a  day  sufficed  for  purposes 
of  drinking  and  washing,  but  to-day  the  average  daily 
amount  of  water  used  for  domestic  purposes  is  usually 
estimated  at  seventeen  gallons  per  person.  In  cities, 
the  average  daily  consumption  per  person  may  be  over 
200  gallons. 

This  enormous  consumption  of  water  has  everywhere 
led  to  the  installation  of  public  water  systems,  a  serv- 
ice which,  obviously,  affects  for  good  or  ill  the  health 
of  the  great  majority  of  people.  Since  the  health  of 
man  is  mainly  affected,  as  far  as  water  is  concerned, 

316 


WATER  317 

by  the  water  he  drinks,  it  would  seem  practicable  to 
have  two  systems  of  water  supply,  one  of  certain  purity 
for  drinking,  and  the  other  for  all  general  purposes, 
which  may  or  may  not  be  pure.  This  double  water 
system  is  used  in  certain  European  cities,  but  it  has 
never  found  favor  in  the  United  States.  The  ob- 
jections are  obvious.  An  impure  water  in  a  household 
would  always  be  a  menace.  While  suitable  for  sewage- 
carrying,  impure  water  could  never  be  used  in  con- 
nection with  eating  utensils.  Carelessness,  ignorance, 
or  confusion  would  at  some  time  be  inevitable  and 
would  always  court  disaster.  It  is  within  the  range  of 
probability  that  new  methods  of  water  treatment  or 
even  the  increasing  consumption  of  water  may  result 
in  the  more  general  adoption  of  some  modified  plan 
of  double  water  systems.  In  general,  the  water  prob- 
lem is  in  itself  a  special  field,  a  field  for  the  cooperative 
activity  of  the  engineer,  the  chemist,  and  the  public 
health  physician. 

Water  and  Disease.  Diseases  in  which  the  causative 
agent  gains  an  entrance  to  the  body  through  the  mouth 
and  digestive  tract  are  largely  due  to  impure  water. 
The  role  6*f  water  in  the  transmission  of  typhoid  fever, 
cholera,  and  dysentery  has  already  been  pointed  out. 
The  water  problem  is  by  no  means  new,  but  the  reali- 
zation of  the  importance  of  water  in  disease  is  com- 
paratively recent.  Nor  is  the  problem  of  water 
restricted  to  large  gatherings  of  people,  as  in  cities. 
Records  show  that  typhoid  fever  was  never  rare  in 
older  days  on  the  more  or  less  isolated  farm. 

The  problem  of  water  is  directly  connected  with 
that  of  human  sewage.  In  general  terms  water  causes 
disease  because  it  contains  disease-causing  bacteria 
derived  from  the  fecal  excretions  of  a  diseased  human 
being.  Obviously  not  all  water  polluted  with  sewage 
will  cause  disease,  but  always,  eventually,  the  sewage 


318  HEALTH  AND  DISEASE 

will  contain  disease-bearing  bacteria  and  water  con- 
taining such  sewage  will  produce  disease.  Theoreti- 
cally, if  all  sewage  was  disposed  of  properly,  the  water 
problem  would  not  exist.  Practically,  it  is  much  more 
effective  and  much  more  economical  to  purify  water 
than  to  be  certain  of  sewage  disposal.  As  Hazen  has 
pointed  out,  one  dollar  invested  in  water  purification 
is  as  effective  as  ten  dollars  devoted  to  sewage  dis- 
posal. 

The  purity  of  water  depends  almost  solely  on  the 
presence  of  pathogenic  bacteria.  A  clear  sparkling 
water  may  be  impure,  while  a  turbid  water  with  a 
distinct  taste  may  be  pure.  Pure  water  in  the  strictest 
sense  is  a  product  of  the  chemical  laboratory.  Water 
is  an  excellent  solvent  and  always  contains  a  con- 
siderable amount  of  dissolved  and  suspended  sub- 
stances. The  color,  turbidity,  taste,  and  odor  of 
water  are  all  due  to  these  dissolved  or  suspended 
substances.  With  the  exception  of  lead  poisoning,  it 
is  uncertain  that  these  substances  in  water,  if  not  forms 
of  bacterial  or  minute  animal  We,  cause  any  disease, 
and,  in  fact,  the  evidence  is  to  the  contrary.  Indi- 
rectly, a  water  disagreeable  in  appearance,  taste,  or 
odor  may  do  harm  if  it  leads  to  insufficient  water  drink- 
ing. Likewise,  water  may  contain  substances  which 
irritate  the  intestinal  tracts  of  sensitive  individuals 
and  thus  cause  diarrhea,  or  a  change  of  water  may  be 
associated  with  constipation  from  the  absence  of  the 
usual  stimulating  substances.  But  in  general  a  change 
in  diet  and  in  the  conditions  of  life  is  usually  responsible 
for  the  intestinal  disorders  associated  with  a  change 
in  residence,  although  the  change  in  water  is  commonly 
held  to  be  at  fault.  There  is  no  evidence  that  the 
formation  of  stones  in  the  body,  such  as  gallstones, 
kidney  stones,  or  stones  in  the  bladder,  has  any  re- 
lation to  the  composition  of  the  water. 


WATER  319 

There  is,  however,  some  evidence  that  goitre  (en- 
largement of  the  thyroid  gland)  is  associated  in  some 
mysterious  way  with  water.  In  the  Swiss  Alps  and 
around  the  Great  Lakes  goitre  is  common.  The  case 
against  some  constituent  of  the  water  in  these  localities 
as  the  direct  cause  of  goitre  is  not  proven  as  yet. 

In  the  case  of  lead  poisoning  the  proof  is  absolute. 
Natural  waters  do  not  contain  lead,  and  lead  in  water 
is  always  derived  from  lead  pipes  or  lead  materials 
in  water  containers  and  the  like.  There  are  various 
conditions  which  favor  the  extraction  of  lead  from  the 
pipe  or  container.  Naturally  stagnant  water,  for 
example,  will  absorb  more  lead  than  running  water. 
Cases  of  lead  poisoning  have  been  traced  to  lead  pipes, 
lead-lined  cisterns,  lead-lined  soda  fountains,  and  lead 
cooking  utensils.  The  symptoms  of  lead  poisoning 
from  water  are  often  obscure,  but  death  or  permanent 
disability  may  result.  It  is  obviously  unjustifiable  to 
use  lead  in  pipes,  cisterns,  and  utensils  which  convey 
water  for  domestic  service,  and  any  water  which  is 
suspected  of  containing  lead  should  be  analyzed. 

Clear  water  and  soft  water  are  desirable  and  con- 
venient, but  they  have  little  relation  to  health  other 
than  that  they  favor  copious  water  drinking  and  wash- 
ing with  soap  and  water,  both  of  which  are  conducive 
to  health.  It  is  always  mechanically  possible  to 
clarify  water,  but  the  community  must  justify  clarifi- 
cation and  softening  on  the  grounds  of  esthetic  con- 
venience and  economy  (to  a  certain  extent  in  the  use 
of  soap),  but  not  on  any  consideration  of  health. 

Sources  of  Water.  The  sources  of  water  are  usually 
classified  as  three,  although  the  sources  overlap :  rain 
water,  ground  water,  and  surface  water. 

Rain  water  is  really  distilled  water  and  is  pure, 
although  it  may  be  contaminated  by  the  vessels  in 
which  it  is  caught  or  preserved  and  by  handling.  Un- 


320  HEALTH  AND  DISEASE 

less  screened,  rain  water  may  serve  as  a  breeding  place 
for  mosquitoes.  Little  rain  water,  as  such,  is  used  for 
drinking  purposes. 

Ground  water  or  subsoil  water  is  from  springs  and 
wells  of  all  sorts.  This  water,  as  well  as  that  from 
artesian  wells,  is  used  for  drinking  by  individuals  and 
small  communities.  Since  the  soil  acts  as  a  filter, 
ground  water  is,  as  a  rule,  pure  and  it  is  polluted  only 
by  gross  and  near-by  sewage  disposal. 

The  pollution  of  a  well  depends  on  several  factors. 
In  the  first  place  the  soil  is  important.  A  sandy  soil 
acts  as  an  admirable  filter  and,  unless  overcharged, 
will  prevent  bacterial  pollution  beyond  a  distance  of 
from  twenty-five  to  fifty  feet.  But  in  sandy  or  rocky 
soils  there  is  always  danger  that  the  pollution  may 
flow  along  crevices.  The  character  of  the  sewage  is 
also  of  importance.  The  old-fashioned  privy,  properly 
screened  from  flies  and  properly  treated  by  the  burial 
of  human  excrement,  enables  a  suitable  soil  to  dispose 
of  the  pollution  and  does  not  permit  a  distribution 
over  an  area  of  more  than  a  few  yards.  On  the  other 
hand,  the  open  cesspool  into  which  water  waste  and 
excrement  run  requires  for  safety  a  considerable  area 
for  the  filtration  of  pathogenic  bacteria.  In  sandy 
soils  the  distance  may  safely  be  as  low  as  twenty-five 
feet,  but  that  necessitates  the  absence  of  crevices  in 
the  soil  and  no  overflow. 

Surface  water  comes  from  the  lakes  and  rivers  and 
its  purity  depends  on  pollution  with  sewage.  With 
the  enormous  increase  in  the  use  of  water  for  all  pur- 
poses and  the  increase  in  the  population,  especially  in 
limited  areas,  surface  water  is  used  more  and  more. 
There  are  a  few  public  water  supplies  which  come  from 
deep  wells,  but  in  most  instances  surface  water  is  used. 
With  the  increased  use  of  surface  water  the  danger  of 
pollution  has  also  increased  through  the  water  carriage 


WATER  321 

system  of  sewage  disposal  and  the  increased  popula- 
tion, as  well  as  the  difficulty  in  safe-guarding  a  much 
larger  supply  of  water.  Most  surface  waters  require 
some  form  of  purification,  as  is  instanced  by  the  ex- 
perience of  the  cities  on  the  Great  Lakes.  Few  cities 
can  so  control  their  water  supply  that  it  requires  no 
treatment. 

Methods  of  Water  Purification.  The  artificial  purifi- 
cation of  water  depends  largely  on  the  same  principles 
by  which  water  is  naturally  purified.  The  essential 
is  the  elimination  of  pathogenic  bacteria.  The  arti- 
ficial purification  of  water  is  less  than  a  hundred  years 
old,  and  in  the  United  States  the  movement  for  such 
purification  is  even  more  recent,  dating  back,  for  the 
most  part,  to  the  noteworthy  investigations  of  the 
progressive  Massachusetts  State  Board  of  Health. 

Water  is  purified  naturally  by  storage.  Pathogenic 
bacteria  tend  to  die  out  in  time  and  all  suspended  matter 
sinks  to  the  bottom.  Sunlight  and  the  contained 
oxygen  in  water,  the  fall  and  spring  turn-over  of  the 
water,  are  all  important  factors  in  making  water  both 
pure  and  clean.  Some  precaution  is  necessary  that 
the  water  of  the  surface  is  not  driven  directly  by  a 
breeze  from  the  inlet  to  the  outlet  without  storage. 
New  York  and  Boston  depend  upon  storage  of  water 
in  artificial  reservoirs  and  in  natural  lakes  and  ponds 
for  the  purification  of  their  water  supply.  The  effec- 
tiveness of  this  method  is  shown  by  the  freedom  of 
these  cities  from  water-borne  diseases.  It  is  obviously 
the  case  that  the  shores  of  the  reservoir,  either  natural 
or  artificial,  should  be  protected  from  pollution.  Ex- 
perience has  shown,  however,  that  it  is  not  necessary 
to  exclude  human  habitations  from  the  shores  of  such 
reservoirs,  although  frequent  and  competent  inspection 
is  necessary.  The  storage  of  water  is  sometimes  used 
as  an  adjunct  to  other  methods  of  purification. 


322  HEALTH  AND  DISEASE 

The  slow  sand  filter  is  a  second  method  of  water 
purification.  Many  of  the  European  cities  and  some 
American  cities  —  Lawrence,  Mass.,  Washington,  D.  C., 
and  Philadelphia  —  make  use  of  beds  of  sand  spread 
over  gravel  in  water-tight  basins.  The  sand  layer 
must  be  removed  and  cleaned  at  intervals.  If  there  is 
much  fine,  suspended  material  —  as  in  many  muddy 
American  rivers,  —  the  sand  filter  becomes  clogged 
and  inoperative. 

The  rapid  sand  filter  is  largely  an  American  develop- 
ment for  water  purification.  In  this  method,  the 
water  is  first  treated  by  some  coagulant,  such  as  sul- 
phate of  aluminum  or  iron,  and  then  the  water  can  be 
rapidly  passed  through  a  sand  filter.  This  method  is 
cheaper  in  construction  but  more  expensive  in  opera- 
tion than  the  slow  sand  filtration  method. 

While  all  the  foregoing  methods  depend  on  the  elim- 
ination, by  some  means  or  other,  of  the  bacteria,  there 
are  a  few  methods  of  water  purification  which  aim 
directly  to  kill  the  bacteria.  Probably  of  first  im- 
portance to  the  individual  is  the  application  of  the 
well-known  principle  that  heat  kills  bacteria.  This 
is  not  feasible  on  a  large  scale,  but  the  individual  can 
be  sure  of  pure  water  by  boiling.  This  will  probably 
always  be  the  method  of  choice  among  campers  and 
among  troops  on  the  march,  away  from  a  water  supply 
of  proven  purity.  It  is  not  necessary  to  bring  the 
water  to  a  boiling  point,  since  the  heat  of  pasteuriza- 
tion (approximately  140°  F.),  continued  for  twenty  to 
thirty  minutes,  is  sufficient.  On  the  other  hand,  ther- 
mometers are  not  always  available  and  there  is  no 
objection  to  boiling  the  water.  The  day's  water  supply 
for  a  camp  can  be  easily  secured  in  a  few  minutes  and 
placed  aside  for  cooling.  The  usual  precautions  are, 
of  course,  necessary  in  the  handling  and  in  the  use  of 
clean  receptacles.  The  flat  taste  of  boiled  water,  so 


WATER  323 

objectionable  to  some  persons,  can  be  largely  obviated 
by  vigorous  shaking. 

Ozone  and  violet  rays  will  sterilize  water,  but  their 
cost  has  so  far  prevented  their  use  on  a  large  scale. 

Calcium  hypochlorite  (chloride  of  lime  or  bleaching 
powder)  is  widely  and  efficiently  used  to  purify  water. 
Only  five  to  fifteen  pounds  of  this  substance  are  neces- 
sary to  treat  a  million  gallons  of  water.  The  cost  is 
one-tenth  that  of  filtration  despite  the  recent  increase 
in  cost.  The  action  depends  on  the  strong  oxidizing 
power  of  the  hypochlorous  acid  which  is  formed  on 
the  addition  of  hypochlorite  of  calcium  to  water. 

Chlorin  is  the  most  recent  substance  used  for  the 
purification  of  water  and  its  use  developed  out  of  that 
of  bleaching  powder.  Chlorin  is  largely  used  as 
liquefied  chlorin  gas  ("  liquid  chlorin  ").  This  puri- 
fying agent  has  been  used  with  great  effectiveness  in 
small  water  supplies  during  the  European  War.  The 
use  of  both  the  bleaching  powder  and  chlorin  may 
generate  unpleasant  tastes  and  odors,  especially  during 
cold  weather.  Care  must  be  taken  against  overdosing 
the  water.  Both  chlorin  and  bleaching  powder  are 
cheap,  harmless,  and  easy  and  rapid  of  use.  Cleve- 
land, Milwaukee,  and  other  cities  use  the  hypochlorite 
method  with  satisfactory  results. 

Copper  sulphate,  in  small  quantities,  is  remarkably 
effective  in  destroying  most  of  the  algae  and  some  of  the 
micro-organisms  in  water.  In  the  amounts  used  copper 
sulphate  is  not  uniformly  successful  in  ridding  drinking 
water  of  living  pathogenic  bacteria. 

Impressed  by  the  long  list  of  water-borne  epidemics, 
particularly  of  typhoid  fever,  over  fifty  per  cent  of  the 
total  population  of  the  United  States  and  eighty  per 
cent  of  the  population  of  cities  over  10,000  are  now 
supplied  with  surface  water  artificially  purified  in  some 
way  or  with  good  water  of  known  purity.  Chicago 


324  HEALTH  AND  DISEASE 

and  Milwaukee  had  to  suffer  from  epidemics  of  typhoid 
fever  from  their  lake  water  supply;  Lawrence  and 
Philadelphia  from  epidemics  from  their  river  water 
supplies,  and  numberless  towns  and  cities  from  epi- 
demics from  smaller  water  supplies  before  the  im- 
portance of  water  purification  was  really  appreciated. 
It  is  both  probable  and  desirable  that  artificial  puri- 
fication of  water  will  increase.  The  method  of  puri- 
fication to  be  used  is  largely  a  question  of  location 
and  of  cost,  and  often  a  combination  of  methods  is 
best.  There  seems  to  be  a  distinct  tendency  toward 
the  use  of  germicides,  not  only  on  account  of  their 
cheapness,  but  also  on  account  of  the  increased 
pollution  of  surface  water  and  the  overburdening  of 
filtration  plants. 

The  responsibility  of  the  individual  on  the  question 
of  pure  water  is  clear.  The  inspection  of  the  water 
supply  will  tell  him  of  the  probability  of  the  pollution 
of  the  water  and  examination  will  reveal  whether  the 
water  is  or  is  not  polluted.  A  single  examination  under 
unusually  favorable  circumstances  will  not  suffice. 
Polluted  water  always  denotes  a  possible,  although 
not  a  positive,  danger.  The  presence  of  colon  bacilli 
(the  common  bacterium  of  the  intestine)  always  indi- 
cates that  water  is  polluted  with  human  excreta, 
though  that  pollution  may  not  contain  disease-causing 
bacteria,  and  the  water  may  be  extremely  palatable 
or  sparkling.  Under  the  circumstances  of  the  evidence 
of  polluted  water,  the  individual  can  always  protect 
himself  by  boiling  the  water.  As  a  member  of  the 
community  it  is  incumbent  on  the  individual  to  em- 
ploy his  best  efforts  to  secure  an  effective  artificial 
purification  to  this  polluted  water,  since  pollution  will 
eventually  lead  to  disease.  In  any  event,  artificial 
purification,  as  natural  purification  of  water,  must  be 
checked  up  by  inspection  and  examination. 


WATER  325 

Bottled  Water.  Many  people,  especially  in  travel- 
ing, drink  bottled  waters  on  the  theory  that  they  are 
safe.  Most  bottled  waters  come  from  springs  or  wells, 
in  other  words  from  ground  water,  which,  under  ordi- 
nary precautions,  is  usually  pure.  Water  which  has 
been  bottled  for  any  length  of  time  may  be  compared 
to  stored  water  in  which  the  bacteria  always  tend  to 
die  out.  As  a  matter  of  fact  the  purity  of  bottled 
water  is  largely  a  question  of  commercial  honesty. 
But  as  has  already  been  indicated,  the  clearness  of 
water,  while  perhaps  stimulating  to  the  taste,  is  not 
synonymous  with  purity.  It  follows  that  the  bottled 
water,  honestly  collected  from  a  ground  water  of  known 
purity,  naturally  tends  to  be  pure  and  this  purity  is 
further  assured  through  storage.  It  also  follows  that 
polluted  water  may  appear  in  bottles  and  that  the 
clarity  of  such  water  is  no  proof  of  its  purity. 

Household  Filters.  It  is  not  uncommon  to  see 
advertised  or  in  operation  in  households  a  small  filter 
which,  it  is  either  implied  or  expressed,  is  designed  to 
make  the  water  bacteria-free  or,  in  any  event,  pure 
and  safe.  As  a  matter  of  fact  bacteria  readily  pass 
through  the  finest  mesh  of  cloth  or  metal.  A  cheese- 
cloth or  screen  affixed  to  a  faucet  will  have  no  effect  on 
the  bacteria,  but  will  only  remove  gross  particles.  It 
is  true  that  such  particles  offend  the  eye,  but  the  real 
pollution  in  water  is  the  invisible  bacteria  which  cannot 
be  removed  by  screening.  Under  appropriate  condi- 
tions a  proper  filter  may  remove  some  pathogenic 
bacteria,  but  the  adjustment  of  such  filters  is  the 
business  of  an  expert.  Even  if  such  a  filter  is  originally 
effective  against  pathogenic  bacteria,  it  certainly  is 
not  to  be  depended  upon  for  constant  use  without  the 
expert  adjustment  and  testing  which  it  practically 
never  receives.  Actually  the  cleaning  of  such  filters 
by  servants  without  any  scientific  knowledge  is  usually 


326  HEALTH  AND  DISEASE 

accompanied  by  the  gross  contamination  of  the  water. 
The  use  of  the  ordinary  household  filter  is,  in  general 
terms,  of  no  value  in  insuring  the  purity  of  water. 

Ice.  Few  instances  of  ice  as  a  carrier  of  infection 
are  on  record,  for,  as  a  rule,  bacteria  live  only  a  short 
time  in  ice.  Typhoid  fever  is  apparently  rarely  trans- 
mitted by  ice,  but  some  of  the  milder  infections  of  the 
intestines,  especially  in  the  Tropics,  are  probably 
traceable  to  ice.  Ice  may  be  contaminated  either  from 
polluted  water  or  in  handling.  Reasonable  care  should 
be  taken  in  the  avoidance  of  polluted  water  as  a  source 
of  ice,  whether  obtained  naturally  or  artificially,  and 
ice  should  be  handled  carefully.  It  should  always  be 
remembered  that  a  water  supply  may  be  polluted  in 
the  process  of  ice-cutting.  It  is  customary  and  de- 
sirable, therefore,  not  to  utilize  water  supplies  for  ice 
production,  unless  there  is  to  be  subsequent  purifica- 
tion of  the  water. 

Swimming  Pools.  The  rapid  and  desirable  increase 
of  favor  with  which  swimming  is  regarded  has  presented 
a  new  and  difficult  problem  of  sanitation.  Frequent 
changing  of  the  water  in  swimming  pools  is  usually 
impossible  on  account  of  expense,  and  the  constant 
use  of  the  water  is  almost  certain  to  cause  pollution. 
A  considerable  number  of  infections  of  the  eyes,  ears, 
nose,  and  throat,  a  few  skin  infections,  and  an  occasional 
internal  infection,  including  typhoid  fever,  have  been 
traced  to  the  use  of  a  polluted  swimming  pool. 

The  sanitation  of  swimming  pools  divides  itself  into 
two  parts,  both  equally  important.  In  the  first  place, 
the  individual  bather  must  exercise  personal  sanitation. 
Obviously  no  person  with  a  communicable  disease  can 
be  allowed  in  a  pool.  Before  entering  the  water,  the 
bather  must  have  a  cleansing  bath  with  soap,  preferably 
in  a  near-by  shower  bath;  the  swimming  pool  must 
not  be  used  for  purposes  of  cleanliness.  As  few  clothes 


WATER  327 

as  possible,  preferably  none,  should  be  worn  in  the  pool, 
and  the  bathing  suits  should  be  carefully  sterilized. 
Without  reasonable  observance  of  the  rules  of  personal 
sanitation  on  the  part  of  the  bathers  no  swimming  pool 
is  safe. 

Even  with  the  most  scrupulous  care  on  the  part  of 
the  bathers,  some  contamination  of  the  water  is  in- 
evitable. The  ideal  water  for  a  swimming  pool  is  one 
which  is  suitable  for  drinking.  This  ideal  can  be 
maintained  at  one  point,  in  any  event,  —  at  the  inlet 
into  the  pool.  To  approach  this  standard  after  use 
by  bathers  the  water  must  be  treated.  The  water 
may  be  purified  by  the  use  of  ozone  or  the  violet  ray 
but  this  is  too  expensive.  The  use  of  "  bleaching 
powder  "  and  chlorin  is  effective,  but  when  they  are 
employed  in  sufficient  amounts  to  be  effective  rapidly, 
these  substances  are  very  objectionable  on  account  of 
the  disagreeable  odor  and  the  irritating  effects  on  the 
eyes,  nose,  and  throat.  Copper  sulphate  in  sufficient 
amounts  —  the  amount  depends  on  the  composition 
of  the  water,  the  amount  of  water,  the  number  of 
bathers,  and  the  frequency  of  change  of  water  —  is 
apparently  very  successful  in  destroying  pathogenic 
bacteria  in  swimming  pools.  The  combined  use  of 
alum  as  a  coagulant,  copper  sulphate  as  a  disinfectant, 
and  refiltration  has  been  shown  to  be  both  effective 
and  economical.  The  particular  method  or  combina- 
tion of  methods  employed  depends  upon  the  special 
conditions. 

In  any  event  a  swimming  pool  to  be  sanitary  re- 
quires the  exercise  of  personal  sanitation  on  the  part 
of  the  bathers ;  the  use  of  water  originally  suitable  for 
drinking,  the  frequent  periodic  examination  of  the 
water  and,  based  on  this,  the  use  of  one  or  more  methods 
of  water  purification. 


CHAPTER  XXI 

SEWAGE 

THE  proper  disposal  of  sewage  involves  two  con- 
siderations, —  the  avoidance  of  the  spread  of  disease 
and  the  avoidance  of  a  nuisance.  Formerly  it  was 
considered  that  sewage  which  constituted  a  nuisance 
was  a  menace  to  health,  but  we  now  know  that  objec- 
tionable as  sewer  gas  and  the  offensive  odors  of  sewage 
are,  the  real  danger  lies  in  the  bacteria  and  in  their 
entrance  to  the  human  body.  With  the  rather  recent 
use  of  water  to  transport  sewage,  sewage  has  become 
less  of  a  nuisance,  but  more  of  a  danger. 

The  usual  methods  of  the  disposal  of  fecal  matter 
are  three :  on  the  ground,  into  the  ground,  or  into 
water.  The  careless  disposal  of  fecal  matter  on  the 
ground  is  always  a  possible  source  of  danger,  whether 
occasionally  in  the  woods,  from  Pullman  cars  —  per- 
haps the  day  will  come  when  the  true  significance  of 
this  procedure  as  regards  health  will  be  appreciated  — 
or  as  a  practice.  In  the  South  the  habitual  deposit 
of  fecal  matter  on  the  ground  is  the  underlying  and 
preventable  cause  of  the  ravages  of  hookworm  disease. 
The  old-fashioned  open  privy,  unscreened  from  flies, 
is  essentially  similar  to  and  subject  to  the  same  con- 
demnation as  the  casual  disposal  of  fecal  matter  on 
the  ground.  The  use  of  such  privies  constitutes  both 
a  nuisance  and  a  danger. 

The  experience  of  camp  sanitation,  especially  in  the 
European  War,  indicates  that  sanitary  privies  of  one 

328 


SEWAGE  329 

sort  or  another  are  both  feasible  and  economical  on  a 
large  scale.  The  privy  must  be  protected  from  the 
flies  which  may  carry  fecal  particles  with  bacteria  a 
considerable  distance.  The  disposal  of  the  fecal  ma- 
terial may  be  into  dry  earth  at  some  distance  from  the 
water  supply,  or  it  may  be  burnt  in  specially  designed 
incinerators,  or  disinfected  by  steam  or  chemicals. 
The  odors  can  be  avoided  by  the  use  of  dry  earth  or 
other  odor-absorbing  substances.  This  method,  rather 
unduly  neglected,  is  particularly  suitable  for  camps, 
isolated  dwellings,  summer  cottages,  and  the  like.  If 
the  fecal  material  is  received  into  water-tight  pails, 
with  a  proper  amount  of  earth  or  similar  substance  and 
protected  against  flies,  and  then  frequently,  preferably 
daily,  disposed  of  into  the  ground  or  treated  with  disin- 
fectants, or  burned,  neither  nuisance  nor  danger  results. 
Sewers  were  originally  constructed  to  drain  waste 
water  and  not  to  transport  fecal  material,  but  with  the 
development  of  the  water  carriage  system  of  sewage 
disposal,  the  problem  became  more  complicated.  The 
cesspool  represents  the  attempt  of  the  individual  or  a 
collection  of  individuals  to  dispose  of  water-carried 
fecal  material.  The  danger  from  a  cesspool  depends 
primarily  on  the  proximity  of  the  water  supply  and  the 
character  of  the  soil.  Generally  the  use  of  cesspools 
follows  the  installation  of  a  public  water  system  which 
will  supply  adequate  water  to  transport  the  sewage 
to  the  cesspool.  In  any  event  the  cesspool  should 
mean  the  abandonment  of  any  near-by  wells.  In  any 
considerable  collection  of  houses  with  cesspools,  pollu- 
tion of  near-by  wells  and  springs  is  probable,  not  only 
through  the  soil,  but  mainly  from  the  overflowing  of 
the  overburdened  cesspools.  Such  cesspools,  suitably 
located,  by  means  of  proper  supervision,  including 
screening  and  occasional  emptying,  can  be  rendered 
both  safe  and  inoffensive.  For  the  small  community 


S30  HEALTH  AND  DISEASE 

it  is  often  safer  as  well  as  more  economical  to  continue 
the  use  of  cesspools  than  to  build  an  elaborate  sewage 
system  which  may  be  very  expensive  to  construct  and 
to  operate  satisfactorily  and  safely. 

The  advent  of  water-carried  sewage  has  not  solved 
the  sewage  disposal  problem  as  bitter  experience  has 
taught  us.  Chicago  ran  its  sewage  into  Lake  Michigan 
and  had  an  epidemic  of  typhoid  fever  from  the  pollu- 
tion of  her  water  supply  from  the  same  source.  Sewage 
discharged  into  rivers  may,  and  often  does,  pollute  the 
water  supply  of  the  towns  further  down.  Pathogenic 
bacteria  may  be  carried  many  miles  in  flowing  water 
and  the  discharges  of  a  single  individual  may,  after 
polluting  a  water  supply,  cause  an  almost  incredibly 
large  epidemic.  Sewage  disposal  into  the  ocean  has 
in  the  past  polluted  shell-fish,  particularly  oysters, 
and  thus  caused  typhoid  fever.  Moreover,  the  dis- 
posal of  sewage  is  always  attended  by  the  possibility 
of  constituting  a  public  nuisance.  As  a  result  of  all 
these  difficulties  some  control  of  sewage  disposal  is 
necessary.  By  regulation  it  is  possible  to  prevent 
oyster  fattening  and  bathing  in  polluted  waters  and  to 
dispose  of  sewage  in  such  a  way  and  at  such  times  as 
not  to  constitute  a  nuisance.  But  perhaps  in  most 
instances  sewage  demands  some  sort  of  treatment 
for  one  or  both  of  the  reasons  given  above,  —  the 
avoidance  of  danger  or  the  avoidance  of  nuisance. 

The  treatment  of  sewage  is  a  problem  of  sanitary 
engineering  in  which  great  advances  have  been  made 
in  twenty-five  years.  There  are  now  many  devices 
and  methods,  all  designed  to  remove  bacteria  from 
the  sewage,  but,  ordinarily,  no  method  completely  re- 
moves all  the  bacteria.  For  example,  ten  to  fifteen 
per  cent  of  the  bacteria  are  removed  by  the  screening 
out  of  suspended  material.  Sixty  to  seventy  per  cent 
are  removed  by  settling  tanks  or  septic  tanks.  Chemi- 


SEWAGE  331 

cal  precipitation  will  remove  from  seventy-five  to 
ninety-nine  per  cent  of  the  bacteria.  The  most  effec- 
tive procedure  is  the  broad  irrigation  method  in  which 
the  sewage  is  discharged  upon  a  considerable  area  of 
land  suitably  arranged.  The  treatment  of  sewage  in 
any  given  instance  varies  widely.  In  some  cases  the 
cost  will  be  the  determining  factor  of  the  method  em- 
ployed, but,  in  general,  sewage  must  be  treated  in  some 
way  to  eliminate  a  public  nuisance  and  to  minimize 
the  danger  to  public  health. 

There  are  certain  obvious  questions  which  arise  in 
the  question  of  sewage  disposal.  Why  is  it  necessary 
to  treat  the  water  supply  and  also  the  sewage?  Why 
not  one  or  the  other?  Why  should  a  community 
downstream  be  obliged  to  undertake  an  elaborate 
engineering  project  to  purify  water  polluted  by  the 
sewers  of  communities  further  upstream  ?  The  answer 
to  these  questions  is  founded  on  experience.  In  the 
first  place  surface  water  of  rivers  is  almost  inevitably 
polluted  even  without  the  discharge  of  sewers  into  the 
river.  Further,  the  additional  pollution  by  sewage, 
if  untreated,  will  overburden  and  perhaps  render  in- 
effective the  most  expensive  and  elaborate  water 
purification  plant.  Then,  gross  pollution  is  a  public 
nuisance.  As  a  result  of  these  considerations,  it  is 
obvious  that  there  should  be  cooperation  in  sanitation 
between  communities.  The  treatment  of  sewage  does 
not  render  the  purification  of  water  unnecessary,  and 
vice  versa.  But,  as  Hazen  has  pointed  out,  of  the  two 
the  purification  of  water  is  the  more  effective  in  the 
saving  of  lives  and  the  more  economical. 

Refuse  and  Garbage  Disposal 

The  problem  of  refuse  and  garbage  disposal  mainly 
concerns  good-sized  communities  and  it  is  only  indi- 


332  HEALTH  AND  DISEASE 

rectly  related  to  health.  Garbage  attracts  flies ;  ashes 
and  street  sweepings  irritate  the  nose  and  throat  and 
favor  infection,  but  the  important  consideration  hi 
this  question  is  the  avoidance  of  a  nuisance. 

The  amount  of  garbage  and  refuse  in  a  large  city 
is  enormous.  In  New  York  City,  for  example,  it  has 
been  estimated  at  a  ton  per  capita  per  year.  In  general, 
there  are  two  methods  of  the  disposal  of  refuse  and 
garbage,  the  mixed  system  and  the  separate  system. 
In  the  mixed  system,  which  is  commonly  used  in 
Europe,  all  the  collected  garbage  is  burnt  in  specially 
constructed  incinerators,  the  material  being  self- 
consuming.  The  end  products  are  ashes,  used  for 
filling  in  land,  and  steam  excess,  which  may  be  sold. 
In  the  separate  system,  commonly  used  in  the  United 
States,  the  ashes  are  used  for  filling  in  land,  the  rubbish 
is  carried  to  the  so-called  "  dump,"  and  the  garbage  may 
be  fed  to  hogs,  usually  by  contract,  dumped  into  the 
sea  or  buried,  or  it  is  treated  at  a  reduction  plant. 
The  end  products  of  a  reduction  plant  are  grease,  which 
is  sold  for  the  manufacture  of  soap,  and  so-called  "tank- 
age "  (solid  particles  of  cooked  garbage),  which  is  used 
as  a  filler  for  fertilizer. 

Under  proper  conditions  both  incineration  and  re- 
duction plants  can  be  operated  without  offensive  odors. 
Under  any  system  of  refuse  disposal,  the  essential 
consideration  is  the  prompt  collection  of  the  refuse. 
If  the  mixed  system  of  disposal  is  used,  it  is  relatively 
simple  to  insure  prompt  collection  and  this  is  attended 
with  less  nuisance. 


CHAPTER  XXII 

OCCUPATIONAL  DISEASES 

WHILE  it  has  long  been  appreciated  that  certain 
trades  were  hazardous  and  that  certain  diseases  were 
connected  with  certain  occupations,  it  is  only  within 
a  few  years  that  society  has  taken  an  intelligent  interest 
in  such  conditions.  The  attitude  of  employers  and  of 
society  as  a  whole  has  been  that  the  worker  must 
assume  all  risks  as  part  of  the  job.  In  fact,  employers 
have  been  and  are,  unless  compelled  by  legislation, 
almost  entirely  unwilling  to  recognize  any  liability  on 
their  part  for  the  health  of  their  workers.  This  has 
been  especially  true  if  the  change  of  conditions  to  im- 
prove the  health  of  employes  necessitated  the  ex- 
penditure of  any  money.  But  throughout  the  world 
there  has  developed  a  movement  to  compel  the  em- 
ployer to  recognize  that  the  employes  have  rights  to 
life  and  limb,  and  health  as  well,  so  that  we  now  find 
employers'  liability  laws  in  most  countries  and  in  most 
of  our  own  states  which  are  at  all  advanced  in  pro- 
tecting the  welfare  of  their  citizens.  This  movement 
has  been  steadily  fought  by  the  employers,  but  we 
now  find  that  society  fairly  generally  recognizes  that 
the  employer  has  a  liability  for  accident  and  disease 
connected  with  employment.  As  in  most  movements 
connected  with  the  community  assuming  a  somewhat 
paternal  attitude  toward  the  individual  citizens,  the 
United  States  has  lagged  far  behind  other  countries 
in  its  attitude  toward  industrial  hygiene,  and,  as  a 

333 


334  HEALTH  AND  DISEASE 

result,  we  find  that  there  is  little  definite  information 
on  the  subject  of  diseases  of  occupation  or  industry  in 
this  country. 

The  following  brief  classification  of  industrial  diseases, 
suggested  by  the  United  States  Public  Health  Service, 
gives  some  idea  of  the  extent  and  prevalence  of  such 
diseases : 

a.  Workers  in  harmful  substances :  Metals,  dusts, 
gases,  vapors,  and  fumes. 

6.  Workers  under  harmful  conditions :  Heat,  mois- 
ture, cold,  confined  air  (all  bad  ventilation),  over- 
crowding, compressed  air,  excessive  light,  strains  of 
muscles,  nerves,  or  special  senses,  and  the  like. 

Industrial  Accidents.  Occupation  affects  the  health 
most  obviously  when  it  exposes  the  worker  to  physical 
accidents.  Certain  trades,  as  war,  aeroplaning,  and 
the  handling  of  high  explosives,  are  inherently  dan- 
gerous, but  others  are  dangerous  only  because  proper 
precautions  are  omitted.  In  the  metal  trades,  for 
example,  there  has  always  been  a  large  number  of 
accidents  caused  by  pieces  of  metal  getting  into  the 
eyes  of  the  workers.  The  general  attitude  of  em- 
ployers towards  the  health  of  the  employes  was  well 
illustrated  here.  In  certain  operations  it  was  impor- 
tant in  the  progress  of  manufacture  that  the  metal 
should  be  kept  dry  and  clean.  This  was  done  effec- 
tively, but  no  effort  was  made  to  prevent  the  injury 
to  the  employe.  Another  dangerous  trade,  a  few 
years  ago,  was  the  machine  laundry.  Women  were 
continually  injuring  their  hands  in  the  mangling 
machine  and  seriously  crippling  their  arms  and  their 
ability  to  gam  a  livelihood.  The  community  was  thus 
forced  to  support  a  crippled  woman  and,  sometimes, 
her  family,  while  the  employer  merely  hired  another 
worker.  One  immediate  result  of  the  usual  employers' 
liability  law  is  that  the  employers  supply  their  machines 


OCCUPATIONAL  DISEASES  335 

with  guards  and  the  crippling  of  the  workers  has  de- 
creased markedly. 

In  many  mines,  even  to-day,  the  omission  of  safety 
devices  and  of  reasonable  precautions  for  the  safety 
of  the  workers  displays  a  brutal  disregard  of  human 
life  and  suffering.  It  is  a  common  fallacy  that  the 
dangerous  trades  are  well  paid,  but,  with  few  ex- 
ceptions, the  exact  contrary  is  true.  In  actual  practice 
the  skilled,  intelligent  worker  naturally  shuns  the 
dangerous  features  of  his  work.  He  can  get  another 
job.  In  consequence  the  dangerous  jobs  fall  to  the 
ignorant  and  unskilled,  who  are,  in  practice,  if  not 
in  theory,  compelled  to  undertake  the  dangerous  tasks 
at  very  little  pay.  This  situation  is  one  of  the  justifi- 
cations of  the  existence  of  stringent  liability  laws. 
While  occasional  accidents  are  apparently  inevitable 
in  many  trades,  it  has  been  found  that,  in  a  general 
way,  it  is  possible  to  avoid  most  of  the  accidents  of 
industry.  It  is  often  merely  a  matter  of  equipping 
dangerous  machines  with  guards  or  changing  the 
details  of  manufacture. 

The  important  relation  of  work  to  fatigue  has  al- 
ready been  indicated.  Briefly  stated,  most  accidents 
happen  at  the  close  of  a  working  day  or  of  a  working 
period.  With  fatigue  the  alert  vigilance  is  relaxed 
and  the  accident  happens  as  a  result  of  the  worker's 
so-called  "  carelessness."  Reasonable  hours  of  labor 
tend  to  prevent  industrial  accidents.  While  fatigue, 
strain,  and  overwork  are  hardly  industrial  diseases, 
they  are  questions  of  industrial  hygiene  in  which  the 
community  is  vitally  concerned.  The  determining 
factor  here  is  the  amount  of  strain  which  the  worker 
has  to  undergo.  Hard  and  fast  rules  as  to  the  amount 
of  strain  and  fatigue  in  any  occupation  cannot  be  laid 
down.  It  is  generally  agreed  that,  at  least  for  women, 
eight  hours  is  a  sufficiently  long  working  day.  In  the 


336  HEAI/TH  AND  DISEASE 

average  occupation,  especially  where  it  is  associated 
with  machinery,  the  eight  hour  day  is  sufficiently  long 
for  any  individual.  Longer  hours  mean  poorer  work, 
more  accidents,  and  the  fatigue  which  keeps  the  worker 
at  all  times  at  a  low  plane  of  effectiveness  and  health. 
The  hours  of  labor  should,  in  the  interests  of  the  com- 
munity as  well  as  of  the  workers,  be  regulated  by  law 
and  controlled  by  an  active  and  real  inspection  of  the 
workshop. 

Special  Occupational  Strains.  Certain  occupations 
are  associated  with  special  strains.  The  strain  on  the 
eyes  may  be  tremendous  and  in  such  cases  the  eye 
strain  may  be  correctly  called  an  occupational  disease. 
Writer's  cramp  is  an  occupational  disease  which  is 
not  so  common  now  as  formerly.  This  condition  simply 
evidences  an  overwork  of  the  nerves  of  the  arm  due  to 
steady  writing.  Recovery  is  extremely  slow.  It  is 
remarkable  and  illustrative  of  the  highly  specialized 
injury  that  sufferers  from  this  affliction  can  usually 
do  everything  else  save  write.  Barbers  suffer  from 
'*  barber's  palsy  "  so  that  they  cannot  work  without 
great  pain. 

Waiters  are  especially  subject  to  flat  feet  caused  by 
standing  for  long  periods  of  time,  a  condition  probably 
aggravated  by  poor  boots.  Flat  feet  are  by  no  means 
limited  to  waiters,  for  the  condition  is  common  in  all 
walks  of  life.  The  cure  and  prevention  is  exercise  of 
the  feet  to  strengthen  the  muscles.  Plates  should  be 
resorted  to  only  when  compulsory. 

Children  get  into  poor  habits  of  posture  at  school. 
Improperly  arranged  and  adjusted  chairs  and  desks 
are  the  cause  of  many  of  the  defects  of  posture  and  of 
many  of  the  troubles  of  the  back.  When  the  faulty 
posture  arises  from  a  habit  acquired  at  school  or  at 
work,  the  associated  difficulties  may  rightly  be  called 
occupational.  We  are  just  beginning  to  realize  how 


OCCUPATIONAL  DISEASES  337 

many  people  readily  acquire  faulty  habits  of  posture 
and  of  walking.  To  a  considerable  extent,  varying  in 
different  individuals,  Nature  compensates  for  this 
strain,  but  such  bad  habits  are  always  potential  causes 
of  suffering.  Most  habits  of  posture  and  walking  are 
acquired  in  childhood,  and  it  is  obviously  desirable 
that  good  rather  than  bad  habits  should  be  acquired. 
The  most  suitable  place  for  this  would  seem  to  be  the 
school  where  proper  posture  and  proper  carriage  should 
be  taught  and  insisted  upon.  Suitable  exercises  to 
develop  proper  posture  are  important,  for,  wherever 
possible,  the  child's  own  muscles  should  be  developed 
so  as  to  hold  him  correctly.  Artificial  supports  and 
braces  are,  unfortunately,  necessary  in  occasional  in- 
stances, but  should  only  be  worn  under  expert  advice 
as  their  use  frequently  retards  the  natural  symmetrical 
development. 

Hygienic  Environment  of  Occupation.  Many  of  the 
ordinary  diseases  may  be  associated  with  occupations 
and  acquired  in  a  particular  occupation,  although  not 
peculiar  to  it.  The  environment  of  the  occupation, 
however,  constitutes  one-third  of  the  total  environment 
of  the  individual.  So  the  condition  of  the  workshop, 
for  example,  is  of  great  importance.  If  the  shop  is 
overcrowded,  poorly  ventilated,  dirty,  and  ill-lighted, 
there  will  be  more  or  less  disease  associated  with  that 
shop.  Sanitary  surroundings,  as  many  employers 
have  discovered,  mean  better  health  for  the  workers 
and  better  and  more  work  for  the  employer.  But 
until  stringent  factory  laws  are  enforced  in  all  the 
states,  we  shall  probably  have  a  large  number  of  un- 
sanitary working  places.  The  most  notorious  of  these 
are  the  "  sweat  shops  "  and,  until  they  are  eradicated, 
the  workers  in  them  will  be  severely  affected  by  the 
air-borne  and  contact  diseases.  Furthermore,  in  such 
shops  fatigue  increases  with  a  resultant  lowered  re- 


338  HEALTH  AND  DISEASE 

sistance  to  all  diseases.  Then  if  a  disease  is  contracted, 
the  result  is  apt  to  be  fatal  on  account  of  the  lowered 
resistance. 

Unhygienic  working  conditions  bring  about  the  same 
illnesses  as  unhygienic  conditions  elsewhere.  The 
high  incidence  of  tuberculosis  among  garment  workers 
in  the  cities  is  attributable,  not  to  the  occupation,  but 
to  the  unhygienic  conditions.  The  inadequate  washing 
facilities,  the  dangerous  common  towel  and  drinking 
cup  are  frequently  the  cause  of  the  spread  of  infection 
among  industrial  workers.  The  community  should 
realize  that  such  shops  are  foci  for  disease  and  that  the 
health  of  the  entire  community  may  be  affected  through 
the  existence  of  conditions  which  at  first  seem  to  apply 
to  the  employes  alone. 

Hygienic  Conditions  in  Special  Trades.  Workers 
who  are  compelled  to  labor  under  conditions  of  extreme 
heat  are  subject  to  diseases  caused  by  this  exposure 
to  unnatural  conditions.  It  is  impossible  for  men  to 
stand  high  temperatures  for  any  length  of  time  without 
prostration.  This  is  illustrated  in  the  case  of  stokers 
on  steamships.  Under  the  conditions  of  work,  we  get 
heat  prostration  and  heat  insanity,  followed  many 
times  by  death.  The  same  conditions  prevail  in  other 
forms  of  industry,  but  the  workers  are  not  usually 
compelled  to  undergo  exposure  for  any  great  length 
of  time.  Workers  who  are  continually  exposed  to 
cold  are  particularly  liable  to  infections.  Dry  air  and 
damp  air  are  common  conditions  in  certain  industries, 
and  the  people  who  work  under  such  conditions  are 
liable  to  bronchial  trouble.  Some  of  these  conditions 
are  difficult  or  impossible  to  remedy,  but,  as  far  as 
possible,  conditions  should  be  normal  as  to  temperature 
and  humidity.  Further,  exposure  to  abnormal  con- 
ditions of  temperature  and  humidity  should  be  as  brief 
as  possible. 


OCCUPATIONAL  DISEASES  339 

Certain  trades  are  known  as  the  "  dusty  trades." 
In  quarries,  for  example,  the  men  work  under  conditions 
of  extreme  dust.  In  all  the  dusty  trades  tuberculosis 
is  common  among  the  workers,  as  well  as  bronchitis, 
asthma,  and  other  diseases  of  the  respiratory  tract, 
especially  if  the  trade  is  combined  with  indoor  work. 
The  irritation  of  the  lungs  and  bronchi  by  the  fine  dust 
particles  predisposes  to  infection.  Adequate  devices 
for  the  protection  of  the  worker  are  available.  By 
preference  the  dust  should  be  removed  as  is  always 
done  when  necessary  for  the  product.  Failing  this,  the 
worker  should  be  supplied  with  and  compelled  to  wear 
a  mask  which  does  not  allow  the  particles  to  penetrate. 

Caisson  disease  afflicts  workers  who  labor  under  the 
high  air  pressure  necessitated  in  digging  tunnels,  for 
instance.  Under  such  conditions  a  Certain  number  of 
workers  will  have  caisson  disease,  a  few  will  die,  and  a 
few  will  be  injured  permanently.  While  working,  the 
men  are  not  bothered,  but  only  when  they  leave  the 
work  and  return  to  the  outside  air.  A  system  of  locks 
with  varying  pressures  of  air  now  decreases  the  danger. 
It  is  only  recently  that  employers  have  used  such  de- 
vices, but  now  that  they  are  liable  in  case  of  accidents 
and  disease,  they  are  extremely  careful  to  see  that  all 
precautions  are  taken  when  the  men  enter  and  leave 
the  places  of  high  air  pressure.  . 

In  certain  industries  where  workers  are  exposed  to 
chemicals,  they  are  subject  to  a  dermatitis  or  irritation 
of  the  skin.  In  other  occupations  there  is  liability  to 
abrasions  of  the  skin  which  make  infection  frequent. 
Two  infections  —  anthrax  and  glanders  —  are  closely 
associated  with  occupations.  Glanders  is  a  disease  of 
horses,  which  may  easily  be  communicated  to  the  men 
who  handle  the  animals.  The  disease  in  man  is  rather 
serious  and  frequently  results  in  death.  Anthrax  is 
essentially  a  disease  of  cattle  and  the  anthrax  spores 


340  HEALTH  AND  DISEASE 

may  be  carried  on  the  hides  and  thus  gain  access 
to  man.  The  anthrax  (or  malignant)  pustule  of  man 
is  always  serious  and  is  not  infrequently  a  fatal  affliction. 

Poisoning  by  fumes  is  associated  with  certain  in- 
dustries. Fumes  may  act  merely  locally  or  they  may 
become  a  general  poison.  Chlorin  gas,  for  example,  acts 
almost  entirely  in  a  mechanical  way.  The  gas  gets 
into  the  lungs  and  causes  irritation  and  swelling  so 
that  actual  strangulation  may  take  place.  There  are 
also  a  number  of  irritating  gases  in  the  manufacture 
of  chemicals.  Benzol,  for  instance,  is  highly  irritating 
and  it  also  affects  profoundly  the  blood  of  the  people 
who  breathe  it. 

Lead  Poisoning.  The  most  important  and  best 
known  of  industrial  poisons  is  lead  poisoning,  an 
industrial  disease  which  has  been  known  since  the  time 
of  the  early  Greeks.  There  are  over  150  industries  in 
which  the  workers  are  subject  to  lead  poisoning,  the 
most  important  being  painting  and  the  preparation  of 
paint.  Potting,  enameling,  caulking,  soldering,  and 
the  rubber  industries  also  present  a  chance  of  lead 
poisoning.  The  greatest  danger  lies  in  the  preparation 
of  lead. 

Lead  gets  into  the  system  in  three  ways.  The  first 
is  by  the  inhalation  of  dust  or  fumes.  Men  who  scrape 
paint  free  a  large  amount  of  dust  which  is  loaded  with 
lead  and  the  worker  inhales  it.  The  inhalation  of  lead 
fumes  is  more  important.  The  second  way  in  which 
lead  poisoning  is  caused  is  by  ingestion.  Artists  are 
apt  to  modify  the  point  of  then*  brush  by  putting  the 
point  into  their  mouths.  Raphael,  .Michael  Angelo, 
and  Correggio  all  suffered  from  lead  poisoning.  House 
painters  are  usually  careless  in  their  habits  and  always 
seem  to  have  more  or  less  paint  on  them.  Paint  may 
get  on  their  hands  and  thence  into  their  mouths  and 
systems.  Lead  may  be  absorbed  through  the  skin, 


OCCUPATIONAL  DISEASES  341 

but  this  method  of  poisoning  plays  but  a  slight  part 
in  the  disease.  Individuals  vary  enormously  in  their 
susceptibility  to  lead  poisoning  and  so  the  individual 
equation  is  an  important  factor.  One  person  will  be 
poisoned  by  an  amount  of  lead  which  will  not  affect 
another  person  in  any  way. 

There  are  four  general  symptoms  of  lead  poisoning. 
The  first  and  most  important  is  the  anemia  from  lead 
poisoning.  In  many  cases  this  anemia  is  the  only 
symptom.  The  second  symptom  is  the  effect  on  the 
nervous  system.  There  is  a  definite  paralysis,  called 
lead  palsy,  which  is  apt  to  affect  the  wrists.  This 
paralysis  may  be  temporary  or  permanent.  In  the 
acute  cases  of  lead  poisoning  a  true  case  of  lead  insanity 
may  appear.  The  third  symptom  of  lead  poisoning 
is  "  lead  cramp  "  in  the  gastro-intestinal  tract.  The 
patient  suffers  from  acute  abdominal  cramps.  Fi- 
nally, the  fourth  symptom  is  arterio-sclerosis. 

For  every  case  of  severe  lead  poisoning  there  are 
many  mild  cases.  In  England,  where  an  attempt  has 
been  made  to  report  the  cases,  it  has  been  found  that 
in  certain  trades  the  incidence  of  the  disease  is  as  high 
as  twenty  to  thirty  per  cent.  Besides  the  use  of  other 
materials  wherever  possible  and  the  disuse  of  lead, 
precautions  should  be  taken  to  prevent  lead  poisoning 
wherever  the  material  is  used.  In  the  case  of  painters 
the  prevention  of  lead  poisoning  is  simple.  Experi- 
ments with  a  large  group  of  painters  have  proved  that 
if  they  follow  the  precautions  laid  down,  none  of  the 
workers  will  contract  lead  poisoning.  One  method  of 
prevention  is  to  wear  gloves,  but  this  the  men  dislike 
to  do.  The  second  precaution  is  to  compel  them  to  get 
the  paint  off  their  hands.  Most  of  the  old-time  painters 
go  along  in  the  same  old  way  and  retain  their  careless 
habits  and  their  lead  poisoning. 

In  the  preparation  of  lead  and  in  exposure  to  the 


342  HEALTH  AND  DISEASE 

very  dangerous  lead  fumes,  the  use  of  respirators  is 
necessary.  The  men  do  not  like  to  use  them,  but 
wherever  the  law  makes  the  employer  liable,  the  respira- 
tors are  generally  worn.  It  is  highly  desirable  that  where- 
ever  possible  other  substances  should  be  substituted 
for  the  dangerous  lead.  Zinc  paints  are  harmless  in 
preparation  and  in  application,  and  have  been  used 
successfully  in  many  places.  The  painters,  however, 
do  not  easily  accustom  themselves  to  zinc  paints,  but 
lead  poisoning  from  paint  is  so  common  that  any  harm- 
less substitute  is  well  worth  a  trial  despite  any  tem- 
porary inconvenience. 

Lead  poisoning  is  practically  unnecessary.  The 
prevention  means  simply  factory  and  personal  hygiene. 
A  careful  worker  may  be  subjected  to  conditions  in- 
volving unavoidable  risks,  but  a  careless  worker  may 
be  poisoned  under  the  best  of  conditions.  The  ex- 
perience of  stringent  legislation  in  Europe  and  England 
indicates,  however,  that  uniform  state  sanitary  laws 
for  the  control  of  the  lead  trades  would  largely  abolish 
lead  poisoning  in  the  United  States. 

Occupational  Diseases  Due  to  Other  Poisons.  Until 
very  recently  poisoning  with  phosphorus  was  prevalent. 
This  was  caused  during  the  manufacture  of  the  so- 
called  "  phosphorus  match."  Phosphorus  poisoning 
was  accompanied  by  a  deforming  disease  of  the  jaw  — 
the  **  phossy  jaw."  For  a  long  time  it  was  known  that 
a  particular  preparation  of  phosphorus  could  be  used 
which  was  not  at  all  poisonous  and  which  made  a 
match  which  could  be  lighted  anywhere.  But  this 
form  of  phosphorus  was  slightly  more  expensive  and  the 
manufacturers  refused  to  use  it.  Finally  a  law  was 
passed  forbidding  the  use  of  poisonous  phosphorus, 
and  now  phosphorus  poisoning  has  practically  dis- 
appeared from  the  United  States  and  most  European 
countries. 


OCCUPATIONAL  DISEASES  343 

Carbon  bisulphide  is  used  to  a  certain  extent  in  the 
rendering  process  to  dissolve  certain  fats.  This  gas 
has  been  recognized  as  extremely  poisonous  and  in 
most  countries  its  use  has  been  forbidden.  Carbon 
bisulphide  is  a  deadly  poison  and  produces  nervous 
diseases  which  may  lead  to  insanity  and  death. 

Nitro-benzol  is  a  dangerous  substance  used  in  the 
manufacture  of  high  explosives.  Workers  with  this 
substance,  who  do  not  wear  respirators,  are  almost 
certain  to  contract  extreme  nervous  disorders. 

Arsenic  was  formerly  used  to  a  large  extent  in  the 
coloring  of  wall  paper,  artificial  flowers,  toys,  and  the 
like,  and  epidemics  of  arsenic  poisoning  resulted.  This 
use  of  arsenic  has  almost  disappeared. 

Mercury  is  used  in  the  manufacture  of  mirrors  and 
thermometers  and  may  cause  acute  poisoning.  Chronic 
mercury  poisoning  produces  a  condition  which  is  known 
as  the  "  trembles."  This  form  of  poisoning  may  be 
avoided  by  the  use  of  the  same  precautions  as  for  lead. 
Wood  alcohol,  antimony,  brass,  and  copper  all  cause  a 
certain  amount  of  poisoning. 

Conclusions.  We  know  relatively  little  about  the 
extent  of  these  occupational  diseases,  but  as  communi- 
ties learn  to  realize  their  importance  to  society  we  shall 
doubtless  learn  more  and,  perhaps,  eliminate  many  of 
them.  In  considering  the  occupational  or  industrial 
diseases  many  factors  have  to  be  weighed.  The  general 
factors  of  work  have  to  be  examined,  and,  furthermore, 
if  a  man  works  in  a  shop  eight  hours,  conditions  during 
the  other  sixteen  hours  must  be  understood. 

The  general  proposition  that  the  voluntary  contract 
between  employer  and  worker  relieves  the  employer  of 
responsibility  in  regard  to  accident  or  disease  con- 
tracted in  his  work  has  been  definitely  settled  in  the 
negative.  The  community  is  slowly  interfering  in 
these  voluntary  contracts,  for,  the  community  argues, 


344  HEALTH  AND  DISEASE 

in  the  long  run  it  is  society  that  suffers  when  the  worker 
is  injured  or  diseased.  In  the  most  obvious  instance 
the  community  has  to  support  a  crippled  worker  and 
his  family.  Consequently  every  year  sees  upon  the 
statute  books  a  new  accumulation  of  labor  legislation, 
legislation,  in  the  main,  restrictive.  The  hours  of 
labor  for  women  and  children  and  on  public  work  are 
becoming  universally  restricted,  and  the  tendency  is 
towards  a  general  restriction  of  the  hours  of  labor. 
Then  there  are  numerous  laws  which  compel  the  use 
of  various  safety  appliances.  Further,  we  have  a  wide 
variety  of  legislation  compelling  factory  inspection 
with  the  view  of  securing  adequate  hygienic  conditions 
in  the  workshop.  Efficient  factory  inspection  is  t*he 
vital  part  of  the  program  for  the  prevention  of  occu- 
pational diseases  and  the  development  of  industrial 
hygiene. 

The  various  employers'  liability  laws,  in  point  of 
fact,  only  fix  penalties.  In  some  ways  the  legislation, 
as  in  the  case  of  accidents  and  lead-poisoning,  lags 
behind  the  available  knowledge.  In  others  there  is 
still  a  great  lack  of  definite  information  upon  which 
to  base  an  intelligent  legislative  program.  The  records 
of  an  industrial  accident  board  show  a  mass  of  con- 
flicting expert  testimony.  In  such  records  the  principle 
is  being  established  that  lead  poisoning,  for  example,  is 
an  accident  attributable  to  the  industry,  just  as  the 
loss  of  a  hand  in  a  mangle.  But  what  is  to  be  said 
of  arterio-sclerosis,  kidney  disease,  and  other  lesions, 
which  are  very  common  among  the  workers  in  lead? 
At  present  the  information  is  generally  too  inadequate 
to  establish  a  causative  relationship  in  any  given  case. 
Likewise  in  a  number  of  industries,  for  example,  those 
associated  with  metals,  with  fumes,  and  with  high 
electric  currents,  peculiar  illnesses  are  not  uncommon, 
concerning  which,  at  the  present  time,  definite  knowledge 


OCCUPATIONAL  DISEASES  345 

is  lacking.  Undoubtedly  we  are  only  on  the  threshold 
of  knowledge  concerning  industrial  diseases.  We  must 
have  an  intensive  study  of  many  occupations  and 
careful  collection  and  statistical  tabulation  of  all  the 
facts.  Such  studies  are  reasonably  common  in  Europe, 
but,  so  far,  the  United  States  has  lagged  behind. 


CHAPTER  XXIII 

THE  FUNCTION  OF  THE  BOARD  OF  HEALTH 

BOARDS  of  health,  departments  of  health,  or  com- 
missioners of  health  have  gradually  developed  with 
the  necessary  delegation  of  the  specialized  activities 
of  the  community  to  one  person  or  to  a  group  of  persons. 
The  presumption  is  that  such  officials  bring  special 
skill  or  knowledge  to  the  administration  of  the  particu- 
lar department  of  the  community's  affairs.  Under 
various  titles  and  schemes  of  organization  boards  of 
health  have  been  in  existence  for  a  long  time,  but  the 
activity  of  such  boards  has  varied  widely.  Forty  or 
more  years  ago,  when  little  was  known  about  disease, 
boards  of  health  were  largely  concerned  with  the  pre- 
vention of  nuisances.  The  smoke  nuisance,  cesspools, 
the  carting  of  garbage,  the  keeping  of  pigs  and  other 
animals  were  supposed  to  be  the  functions  of  such 
boards.  We  now  know  that  nuisances  are  not  neces- 
sarily menaces  to  health,  and,  while  boards  of  health 
may  be  given  the  control  over  them,  it  is  hardly  an 
important  function. 

The  control  of  epidemics  has  been  fairly  universally 
delegated  to  boards  of  health,  together  with  quite 
extraordinary  powers.  These  powers,  however,  were 
given  with  such  epidemics  as  smallpox  in  mind.  Where 
only  a  few  diseases  were  formerly  supposed  to  be  com- 
municable, the  present  list  of  known  communicable 
diseases  is  long.  So,  whatever  the  authority  to  control 
epidemics,  public  opinion  is  not  ready  to  countenance 

346 


FUNCTIONS  OF  BOARDS  OF  HEALTH  347 

the  exercise  of  such  authority  in  other  diseases,  as  it 
is  in  the  case  of  smallpox,  leprosy,  or  infantile  paralysis. 

Unfortunately  the  general  public  has  no  clear  idea  as 
to  the  functions  or  the  scope  of  health  boards.  In 
addition  the  public  is  convinced  that  boards  of  health 
are  the  proper  prosecuting  agency  in  the  adulteration 
of  milk  or  foods,  or  in  the  substitution  of  oleomar- 
garine for  butter.  Adulteration  of  foods  and  mis- 
branding  are  not  essentially  matters  of  health,  but,  in 
reality,  concern  the  police  department,  like  any  attempt 
to  obtain  money  under  false  pretences.  Then,  too, 
the  confusion  in  the  minds  of  the  public  concerning 
boards  of  health  is  sometimes  reflected  in  the  caliber 
of  the  men  appointed  or  elected.  In  Massachusetts  it 
required  legislation  to  compel  cities  and  towns,  in 
which  the  selectmen  did  not  act  as  the  board  of  health, 
to  have  a  medical  man  on  the  boards.  Moreover, 
boards  of  health  are  handicapped  by  insufficient  ap- 
propriations, for  many  unhygienic  conditions  require 
inspections  before  they  can  be  detected  and  corrected. 
The  United  States  government  sets  a  rather  poor  ex- 
ample, although  some  progress  is  being  made.  But 
our  national  government  still  devotes  more  attention 
and  more  money  to  the  statistics  of  hogs  and  corn 
and  their  diseases,  and  their  correction  and  pre- 
vention, than  to  similar  statistics  and  measures  for 
its  citizens. 

In  spite  of  lack  of  funds,  public  indifference,  and 
other  handicaps,  boards  of  health  and  health  officials 
have  accomplished  much  good.  The  studies  of  the 
Massachusetts  State  Board  of  Health,  which  date  back 
many  years,  are  notable  contributions  to  sanitary 
science.  The  United  States  Public  Health  Service 
has  many  important  achievements  to  its  credit;  the 
work  against  plague  in  California  is  one  among 
many.  But  in  general,  boards  of  health  unsupported 


348  HEALTH  AND  DISEASE 

by  public  opinion,  hampered  by  insufficient  funds,  and 
handicapped  by  politics,  have  not  been  effective  in 
small  communities  and  only  moderately  so  in  large  com- 
munities. Unquestionably  the  greatest  handicap  has 
been  the  lack  of  an  intelligent  public  opinion.  Within 
forty  years  the  new  preventive  medicine  has  appeared 
and  has  developed  rapidly.  Each  new  discovery  has 
meant  the  discarding  of  an  old  policy  or  an  old  regu- 
lation of  the  board  of  health.  But  what  is  more  im- 
portant is  that  the  public  has  not  as  yet  assimilated  a 
reasonable  amount  of  this  new  knowledge  and  has  not 
yet  been  able  to  visualize  at  all  clearly  the  scope  and 
functions  of  a  present-day  board  of  health. 

The  department  of  health  in  a  community  should  be 
the  official  authority  on  health  for  that  community. 
Obviously  its  personnel  should  have  special  knowledge 
or  skill  in  the  matter  of  health  and  should  concern 
themselves  with  everything  that  involves  the  health 
of  the  individual  or  the  community.  An  effective 
board  of  health  must  undertake  the  following  functions, 
which  may  be  classified  as  follows. 

Vital  Statistics.  This  is  merely  the  bookkeeping  of 
health.  Such  statistics  include  not  only  statistics  of 
births  and  deaths,  but  also  accurate  records  of  cases 
of  disease.  They  must  include  the  incidence  of  all 
communicable  diseases  and  of  any  other  disease  con- 
cerning which  information  is  desirable,  such  as  oc- 
cupational diseases,  pellagra,  and  the  like. 

Sanitary  Engineering.  The  function  of  the  puri- 
fication of  the  water  supply  and  the  disposal  of  sewage 
belongs  to  the  board  of  health.  This  is  gradually  be- 
coming more  and  more  a  community  problem,  for,  as 
has  been  shown,  the  relation  of  water  and  sewage  to 
health  is  close. 

Control  of  Communicable  Diseases.  TJiis  is,  per- 
haps, the  most  important  function  of  the  health~Boara. 


FUNCTIONS  OF  BOARDS  OF  HEALTH  349 

The  control  of  communieablediseases  means  investi- 
"case  of  communicable  disease 


the~ca!I5c  as  well  as  llu;-pfe-~ 

ventiorTof  the  spread  of  the  disease  from  any  individual 
case.  The  actual  measures  of  quarantine,  isolation, 
and  disinfection  vary  with  each  disease  and  the 
community  should  hold  the  health  board  responsible 
for  the  efficiency  of  all  such  measures.  The  prob- 
lem of  the  communicable  diseases  is  so  large  that 
often  the  control  of  tuberculosis  is  regarded  as  a 
separate  function. 

Laboratory.  Early  diagnosis  of  communicable  dis- 
ease is  essential  to  its  prevention.  The  community 
is  the  gainer  by  furnishing  opportunity  for  such  ex- 
aminations, which,  in  many  instances,  are  beyond  the 
power  of  the  busy  practitioner.  Such  examinations 
include  those  of  the  sputum  for  tubercle  bacilli,  the 
examination  of  cultures  from  the  throat  for  diphtheria, 
the  examination  of  the  blood  for  the  reaction  of  syphilis 
or  of  typhoid  fever,  the  examination  of  stools  for 
typhoid  bacilli,  and  the  like.  As  a  part  of  the  labora- 
tory function  may  well  come  the  supervision  or  actual 
supply  of  such  biological  products  as  smallpox  vaccine, 
anti-typhoid  vaccine,  and  diphtheria  antitoxin.  The 
State  Board  of  Health  in  Massachusetts  wisely  argued 
years  ago  that  if  the  state  law  compelled  vaccination 
for  the  protection  of  health,  it  was  the  manifest  duty 
of  the  state  board  to  furnish  vaccine  of  known  purity. 

Chemical  Examination.  This  includes  the  examina- 
tions of  food  products  and  the  like,  including  milk. 
The  examination  of  milk  is  of  great  importance  in 
protecting  health.  Examinations  of  other  foods  may 
also  be  of  importance,  but  they  are  usually  devoted  to 
the  detection  of  fraud.  While  such  activity  is,  perhaps, 
not  essentially  a  function  of  the  board  of  health,  yet 
it  has  apparently  become  so  by  general  custom. 


350  HEALTH  AND  DISEASE 

Education.  An  extremely  important  function  of 
boards  of  health  is  the  proper  dissemination  of  avail- 
able knowledge  concerning  disease  and  its  prevention. 
In  some  instances  the  control  of  disease  depends  on 
the  personal  habits  of  individuals,  and  in  practically 
all  instances  even  the  most  autocratic  control  requires 
some  cooperation  from  the  individuals  of  the  com- 
munity. Our  present  knowledge  of  health  affairs  has 
considerably  distanced  our  application  of  this  knowl- 
edge. This  application  depends  on  the  intelligent 
cooperation  of  individuals  not  only  in  the  actual  carry- 
ing out  of  instruction,  but  also  in  the  creation  of  a 
public  opinion  which  alone  will  support  those  regula- 
tions of  the  health  authorities  which  may  interfere 
with  personal  interests. 

Industrial  Hygiene.  The  role  of  industries  in  affect- 
ing health  is  sufficiently  important  to  warrant  special 
study.  Such  study  is  essentially  a  function  of  the 
health  department. 

Infant  Mortality.  In  large  communities  and  in 
collections  of  communities,  as  the  state  and  nation, 
the  control  of  infant  mortality  represents  a  separate 
function  in  itself.  The  prevention  of  infant  mortality, 
of  course,  is  in  a  way  covered  by  other  functions  of 
the  board  of  health,  yet  the  importance  and  specialized 
nature  of  certain  aspects  of  the  problem  frequently 
make  separate  treatment  and  special  attention  de- 
sirable. 

School  Hygiene.  The  control  of  the  health  of  school 
children,  the  future  parents  of  the  race,  is  extremely 
important  to  the  community.  Every  state  spends 
large  sums  on  the  education  of  children  who  will  die 
of  preventable  disease  before  that  education  can  be 
utilized.  It  is  in  youth  that  sound  health  habits  are 
best  formed.  Many  communities  are  recognizing  the 
importance  of  the  health  of  school  children  by  the 


FUNCTIONS  OF  BOARDS  OF  HEALTH  351 

introduction  of  school  nurses,  school  physicians,  and 
the  increased  care  of  the  sanitation  and  hygiene  of 
the  schoolroom. 

A  higher  degree  of  health  is  obtainable  under  mili- 
tary discipline  than  under  any  other  conditions.  The 
health  of  the  Canal  Zone  is  a  brilliant  illustration  of 
the  effectiveness  of  sanitary  regulations  under  military 
rule.  The  health  organization  of  the  Canal  Zone  under 
Surgeon  General  Gorgas  was  able  to  enforce  its  regu- 
lations. If  any  community  or  nation  is  to  approach 
the  sanitary  effectiveness  of  military  rule,  it  is  necessary 
to  develop  intelligent  cooperation  between  the  indi- 
vidual and  the  community  as  represented  by  the  health 
authorities.  No  separation  between  community  health 
and  personal  health  is  possible.  The  individual  shares 
in  the  health  or  disease  of  his  community,  and  he  has, 
therefore,  his  share  in  the  responsibility. 

In  the  long  run  health  (or  the  prevention  of  disease) 
is  a  purchasable  commodity,  and  it  is  not,  perhaps, 
cheap.  So  it  is  the  true  function  of  the  health  organi- 
zation to  bring  it  about  that  the  individuals  and  the 
community  receive  the  full  value  of  all  money  expended 
for  health. 


CHAPTER  XXIV 


THE  collection  of  vital  statistics  is  a  fundamental 
procedure  in  the  prevention  and  control  of  disease. 
In  order  to  devise  and  test  methods  of  disease  preven- 
tion, it  is  necessary  to  have  records  of  births  and  deaths 
and  also  a  record  of  the  diseases  which  caused  the 
deaths.  The  necessity  for  collecting  and  preserving 
such  figures  has  been  recognized  by  almost  every  nation 
in  the  world  except  the  United  States.  We  have  in 
this  country  a  complete  record  of  the  number  of  cattle, 
sheep,  and  hogs,  and  a  record  of  every  legal  procedure, 
but  the  statistics  which  concern  human  lives  are  un- 
available. It  is  true  that  every  ten  years  we  have  a 
census,  but  such  statistics  are  the  only  vital  statistics 
which  are  at  all  accurate.  A  number  of  the  states  make 
no  pretence  of  keeping  a  record  of  even  the  births, 
deaths,  and  marriages. 

At  the  present  time  we  get  a  report  of  the  deaths 
in  the  '*  registration  area  "  of  the  United  States.  This 
area  includes  about  two-thirds  of  the  country.  Basing 
our  statistics  on  the  results  from  the  registration  area 
we  are  able  to  estimate  such  important  things  as  the 
number  of  deaths  from  typhoid  fever,  pneumonia, 
tuberculosis,  and  other  diseases,  but,  obviously,  such 
estimates  are  far  from  accurate. 

This  matter  of  vital  statistics  is  done  much  better 
in  other  countries.  By  the  use  of  their  careful  statistics, 
it  has  been  possible  to  find  out  what  factors  conduce 

352 


VITAL  STATISTICS  353 

the  most  to  diminish  the  mortality  of  disease.  In  the 
case  of  tuberculosis,  for  instance,  it  was  found  out 
through  statistics  that  the  segregation  of  the  advanced 
cases  was  the  greatest  factor  in  the  decrease  of  the 
mortality. 

It  would  seem  that  it  should  be  obvious  to  every  one 
that  we  must  have  vital  statistics  on  births,  deaths, 
and  marriages.  The  possession  of  a  birth  certificate 
may  be  required  in  many  ways  by  an  individual  during 
his  lifetime.  After  reliable  statistics  concerning  the 
number  of  deaths  have  been  secured,  it  is  further 
necessary  to  secure  the  causes  of  death,  and,  then,  the 
reporting  of  the  actual  cases  of  disease  —  morbidity 
statistics.  At  the  present  time,  as  a  result  of  our  lack 
of  health  statistics,  we  have  little  idea  how  wide- 
spread industrial  diseases  are.  The  only  way  in  which 
we  can  make  progress  is  to  have  available  in  a  regis- 
tration area  not  only  the  number  of  deaths  but  also 
the  number  of  cases  of  lead  poisoning,  for  example. 
Again,  it  may  be  necessary  to  determine  the  efficacy 
of  diphtheria  antitoxin,  but  we  are  absolutely  unable 
to  do  this  unless  we  have  accurate  statistics  regarding 
diphtheria. 

The  reporting  of  certain  diseases  is  necessary  in 
addition  to  their  value  for  statistics,  for  only  in  this 
way  can  we  prevent  their  spread.  If  smallpox,  for 
example,  were  able  to  exist  without  being  reported  to 
the  health  authorities,  it  would  be  perfectly  possible 
for  an  epidemic  of  the  disease  to  start  up  and  assume 
such  headway  that  suppression  would  be  difficult. 

When  the  collection  of  reports  of  disease  was  first 
begun,  there  was  tremendous  opposition,  but  with  the 
gradual  increase  of  knowledge  about  communicable 
diseases,  this  opposition  has  died  down.  Tuberculosis 
has  only  recently  been  placed  on  the  list  of  diseases 
to  be  reported,  although  an  understanding  of  the 


354  HEALTH  AND  DISEASE 

disease  indicates  how  necessary  this  is.  People  seem 
to  have  a  peculiar  objection  to  the  reporting  of  tuber- 
culosis and  the  disease  is  not  reported  so  accurately 
as  should  be  the  case.  As  a  result  of  the  attitude  of 
the  people,  a  curious  situation  existed  until  very  re- 
cently in  Massachusetts,  where  more  people  died  from 
tuberculosis  than  there  were  cases  reported.  Such 
a  situation  can  only  be  improved  by  the  education  of 
the  people  so  that  they  shall  appreciate  the  benefit  to 
the  community  and  to  themselves  through  having 
tuberculosis  reported. 

At  the  present  time  there  is  considerable  discussion 
about  the  reporting  of  the  venereal  diseases.  The 
same  arguments  are  used  against  reporting  such  diseases 
that  have  been  used  against  the  reporting  of  all  the 
other  diseases.  But  people  entirely  miss  the  point  of 
the  desirability  of  reporting  the  venereal  diseases.  We 
need  statistical  evidence  of  them  in  the  hope  that  by 
reporting  them  something  active,  something  remedial, 
will  come  out  of  the  findings.  Statistics  are  entirely 
impersonal,  absolutely  oblivious  of  the  individual,  and 
utterly  unconcerned  with  his  personal  secrets. 

Vital  statistics  have  been  called  the  "  bookkeeping 
of  humanity.*'  They  are  necessary  for  safeguarding 
our  health  and,  until  we  can  procure  additional 
and  accurate  statistics,  we  are  badly  handicapped  in 
attempting  to  cope  with  the  diseases  which  afflict  the 
community. 


APPENDIX 


COMPOSITION  OF  AMERICAN  FOODS  ACCORDING  TO  ATWATER  AND  BRYANT 


REFUSE 

WATER 

PROTEIN 

FAT 

CAR- 
BOHY- 
DRATES 

ASH 

FUEL 
VALUE 

PER 

POUND 

Beef,  cooked 

Roast    .... 

48.2 

22.3 

28.6 

1.3 

1620 

Round  steak  .     . 

63.0 

27.6 

7.7 

1.8 

840 

Beef,  canned 

Corned  .... 

51.8 

26.3 

18.7 

4.0 

1280 

Dried     .... 

44.8 

39.2 

5.4 

11.2 

960 

Tongue       .     .     . 

51.3 

19.5 

23.2 

4.0 

1340 

Veal,  breast  .     .     . 

24.5 

51.3 

15.3 

8.6 

.8 

645 

Let?  . 

11.7 

63.4 

18.3 

5.8 

1.0 

585 

Lamb,  cooked 

Chops    .... 

13.5 

40.1 

18.4 

26.7 

1.2 

1470 

Leg,  roast  .     .     . 

67.1 

19.7 

12.7 

.8 

900 

Mutton,  cooked 

Leg,  roast  .     .     . 

50.9 

25.0 

22.6 

1.2 

1420 

Pork,  fresh 

Chops    .... 

19.3 

40.8 

13.2 

26.0 

.8 

1340 

Ham      .     .     -    . 

12.2 

35.8 

14.5 

33.2 

4.2 

1670 

Bacon    .... 

8.7 

18.4 

9.5 

59.4 

4.5 

2685 

Sausage      .     .     . 

39.8 

13.0 

44.2 

1.1 

2.2 

2125 

Poultry,  cooked 

Chicken,  fricassee 

67.5 

17.6 

11.5 

2.4 

1.0 

855 

Turkey,  roast 

52.0 

27.8 

18.4 

1.2 

1295 

Fish 

Bass       .... 

55.0 

35.1 

8.4 

1.1 

.5 

200 

Cod  

29.9 

58.5 

11.1 

.2 

.8 

215 

Mackerel    .     .     . 

44.7 

40.4 

10.2 

4.2 

.7 

365 

Salmon       .     .     . 

34.9 

40.9 

15.3 

8.9 

.9 

660 

Shad      .... 

50.1 

35.2 

9.4 

4.8 

.7 

380 

Trout    .... 

48.1 

40.4 

9.9 

1.1 

.6 

230 

Cod,  salt    ... 

24.9 

40.2 

19.9 

.4 

18.5 

315 

Sardines     .     .     . 

5.0 

53.6 

23.7 

12.1 

5.3 

950 

Caviar  .... 

38.1 

30.0 

19.7 

7.6 

4.6 

1530 

355 


356  APPENDIX 

COMPOSITION  OF  AMERICAN  FOODS  —  Continued 


REFUSE 

WATER 

PROTEIN 

FAT 

CAR- 
BOHY- 
DRATES 

ASH 

FUEL 

VALUE 

PER 

POUND 

Fish  —  Continued 

1 

Crabs     .... 

52.4 

36.7 

7.9 

.9 

.6 

1.5 

195 

Lobster      .     .     . 

61.7 

30.7 

5.9 

.7 

.2 

.8 

140 

Oysters       .     .     . 

81.4 

16.1 

1.2 

.2 

.7 

.4 

45 

Scallops      .     .     . 

80.3 

14.8 

.1 

3.4 

1.4 

345 

Eggs,  boiled  .     .     . 

11.2 

65.0 

11.7 

10.7 

.7 

680 

Butter  

11.1 

1.0 

85.0 

3.0 

3605 

Cheese,  American  . 

31.6 

28.8 

35.9 

.3 

3.4 

2055 

Cream  .... 

34.2 

25.9 

33.7 

2.4 

3.8 

1950 

Milk,  condensed 

26.9 

8.8 

8.3 

54.1 

1.9 

1520 

Evaporated    .     . 

68.2 

9.6 

9.3 

11.2 

1.7 

780 

Whole    .... 

87.0 

3.3 

4.0 

5.0 

.7 

325 

Bread,  gluten     .     . 

38.2 

9.3 

1.4 

49.8 

1.3 

1160 

Crackers,  butter 

7.2 

9.6 

10.1 

71.6 

1.5 

1935 

Graham      .     .     . 

5.4 

10.0 

9.4 

73.8 

1.4 

1955 

Pie,  apple      .     .     . 

42.5 

3.1 

9.8 

42.8 

1.8 

1270 

Lemon  .... 

47.4 

3.6 

10.1 

37.4 

1.5 

1190 

Candy  

96.0 

1785 

Sugar   

100.0 

1860 

Vegetables 

Asparagus,  cooked 

91.6 

2.1 

3.3 

2.2 

.8 

220 

Cabbage     .     .     . 

15.0 

77.7 

1.4 

.2 

4.8 

.9 

125 

Celery   .... 

20.0 

75.6 

.9 

.1 

2.6 

.8 

70 

Corn,  green    .     . 

61.0 

29.4 

1.2 

.4 

7.7 

.3 

180 

Lettuce      .     .     . 

15.0 

80.5 

1.0 

.2 

2.5 

.8 

75 

Onions,  cooked    . 

91.2 

1.2 

1.8 

4.9 

.9 

190 

Potatoes     .     .     . 

20.0 

62.6 

1.8 

.1 

14.7 

.8 

310 

Tomatoes  .     .     . 

94.3 

.9 

.4 

3.9 

.5 

105 

Olives  

19.0 

52.4 

1.4 

21.0 

3.5 

2.7 

975 

Pickles      .... 

93.8 

1.1 

.4 

4.0 

.7 

110 

Squash      .... 

50.0 

44.2 

.7 

.2 

4.5 

.4 

105 

Fruits 

Apples  .... 

25.0 

63.3 

.3 

.3 

10.8 

.3 

220 

Bananas     .     .     . 

35.0 

48.9 

.8 

.4 

14.3 

.6 

300 

Grapes       .     .     . 

25.0 

58.9 

1.0 

1.2 

14.4 

.4 

335 

Oranges      .     .     . 

27.0 

63.4 

.6 

.1 

8.5 

.4 

170 

Strawberries  .     . 

5.0 

85.9 

.9 

.6 

7.0 

.6 

175 

Nuts,  edible  portion 

Almonds    .     .     . 

4.8 

21.0 

54.9 

17.3 

2.0 

3030 

Peanuts      .     .     . 

9.2 

25.8 

38.6 

24.4 

2.0 

2560 

Chocolate      .     .     . 

5.9 

12.9 

48.7 

30.3 

2.2 

2860 

APPENDIX 


357 


COMPOSITION  OF  AMERICAN  FOODS  —  Continued 


REFUSE 

WATEB 

PBOTEIN 

FAT 

CAB- 

BOHY- 
ifrlATES 

ASH 

FUEL 
VALUE 

PEB 

POUND 

Soups,  canned 
Bouillon     ,     .     . 

96.6 

2.2 

.1 

.2 

.9 

50 

Chicken     .     .     . 
Pea  

93.8 
86.8 

3.6 
3.6 

.1 

.7 

1.5 
7.6 

1.0 
1.2 

100 
235 

Hash    

80.3 

6.0 

1.9 

9.4 

2.4 

365 

Breakfast-foods 

Cracked  wheat    . 

10.1 

11.1 

1.7 

75.5 

1.6 

1685 

Shredded  wheat  . 

9.6 

12.1 

1.8 

75.2 

1.3 

1700 

Oatmeal,  boiled  . 

84.5 

2.8 

.5 

11.5 

.7 

285 

Rolled  oats     .     . 

7.7 

16.7 

7.3 

66.2 

2.1 

1850 

Rice,  boiled    .     . 

72.5 

2.8 

.1 

24.4 

i 

.2 

510 

INDEX 


ABBE,  102 

Abscesses,  147 

Abnormal,  standards  for,  6 

Abnormalities,  5,  17 

Absorption  of  food,  27,  58,  59 

Accidents,  to  eyes,  39 

and  alcohol,  117,  122 
fatigue,  104-107 

industrial,  334-336 

statistics  of,  105 
Acidity  of  structures,  43 
Acne,  89 

Actinomyces,  161 
Actinomycosis,  161,  244 
Activity,  voluntary  bodily,  26, 94,  97 

excessive,  40,  117 
Adenoid  facies,  146 
Adenoids,  146,  147 
Aerobes,  162 

Age  incidence  in  pneumonia,  212 
Agramonte,  273 

Air,  4,  29,  66,  67,  74-83,  85,  86,  87, 
96,  143,  148,  154,  165,  210, 
212,  226,  230,  231,  242,  288, 
328 

as  a  cooking  agent,  80,  81 

composition  of,  75-76 

damp,  338 

deep  breathing  of,  82,  83 

drafts  of,  83 

dry,  338 

dust  in,  78 

expired,  75 

humidity  of,  76-78 

inspired,  75 

night,  82 

ozone  in,  79 


Air  passages,  78 
pressure  of,  79,  80 
sewer  gas  in,  78,  79 
vitiated,  145 
and  climate,  81,  82 
Air-borne   diseases,   148,   169,   177, 

195-241,  337 
cerebro-spinal-meningitis,       231- 

233 

children's  diseases,  203-209 
coughs  and  colds,  196-198 
diphtheria,  198-203 
general  considerations  in,  209-212 
influenza,  198 
pneumonia,  212-214 
smallpox,  233-241 
tuberculosis,  214-231 
Albinism,  17 
Albumen,  30 

Alcohol,    29,    30,    34,    35,    36,    68, 
113-125,  127,  132,  133,  137, 
150,  151,  165,  244 
a  food,  34,  35,  114 
a  medicine,  114-116 
excess  of,  120,  121 
habit,  119 

immediate  effects  of,  116-118 
in  France,  118 

Italy,  118 

not  a  stimulant,  114,  115 
patent  medicine,  129 
remote  effects  of,  118 
solution  of,  problem,  123-125 
and  accidents,  117 
crime,  122 
digestive  tract,  117 
disease,  121,  122 
exposure,  117 


359 


360 


INDEX 


Alcohol  and  posterity,  122 
poverty,  123 
Teutonic  races,  118 
venereal  disease,  117 
work,  117 
Alcoholic  insanity,  121 

neuritis,  121 
Alcoholics,  16 

irregular  habits  of,  122 

and  infectious  disease,  121,  122 
Alcoholism,  175 
Ales,  34 

Alimentary  tract,  189 
Alkali  in  soda,  48 
Almonds,  50 
Alum,  327 
Ammonia,  115 
Amoeba,  162,  192 
Anaerobes,  162 

Anaphylaxis,  48-51,  72,  89,  203 
Anatomy,  human,  4 
Andalusian  fowl,  19 
Anemia,  43,  248,  284  341 
Anesthetics,  6 
Aneurysm,  252,  256 
Animal  experimentation,  4,  6,  7,  11, 

215,  238-241 
Animals,  carnivorous,  62 

common  diseases  of,  155 

herbivorous,  30,  31,  62 

omnivorous,  62 
Anopheles  mosquito,  276 
Anterior  poliomyelitis,  158,  294 

See  also  INFANTILE  PARALYSIS 
Anthrax,  157,  236,  291,  294,  339,  340 
Anti-bodies,  172,  277 
Antimeningitis  serum,  174,  175 
Antimony,  343 
Antisepsis,  149,  166 
Antitoxin,  157,  172,  175,  208,  214, 

245,  349,  353 
Antivaccination,  238-241 
Antrum  of  Highmore,  148 
Apoplexy,  179 
Appendicitis,  298 
Appetite,  loss  of,  44 
Apples,  56 
Aristocrats,  11,  12 


Aristotle,  245 

Armies,  feeding  of,  54 

Arsenic,  343 

Arseno-benzol,  129,  258 

Arterial  disease,  179 

Arterio-sclerosis,  122,  252,  255,  256, 

295,  341,  344 
Arthritis,  299 
Asepsis,  6,  166,  204 
Ash,  26,  28-29 
Asiatic  cholera,  161,  294 
Asparagus,  34 
Asphyxiation,  76 
Assimilation,  42 
Association,  10 
Asthma,  49,  129 

cure,  129 

dog,  49 

horse,  49,  50 
Astigmatism,  136,  139 
Ataxia,  17 
Athletes,  45,  95,  97,  98 

longevity  of,  99 
Athletic  heart,  97,  98 
Atmospheric  pressure,  79,  80 
Autopsy,  5,  215 

B 

BACH,  17 
Bacilli,  161 

anthrax,  162 

boiling  of,  164 

cold,  196 

diphtheria,  161,  174,  188,  201,  202 

dysentery,  192 

influenza,  196,  198 

tetanus,  174 

typhoid,  161,  162,  165,  180,  182, 
183,  186,  187 

tubercle,  161,  162 

See  TUBERCLE  BACILLUS 
See  also  BACTERIA 
Bacillus, 

Klebs-Loeffler,  198 

leprosy,  289 

pestis,  280 

whooping  cough,  208 


INDEX 


361 


Backache,  104 
Bacon,  54-56 
Bacteria,  155 

characteristics  of,  162,  163 

destruction  within  the  body,  179 
outside  the  body,  163-165 

indirect  methods  of  control,  166, 
167,  192 

and  air,  76,  78,  79,  81,  83 
food,  52,  64,  66-73 
heat,  322 
inflammation,  297 
light,  138 
the  skin,  92 
the  teeth,  142-145,  149 

See  WATER,  MILK,  SEWAGE 
Bactericidal  substances,  174,  175 
Bacteriology,  4,  73,  78,  156, 158,  196 
Baldness,  90 
Bananas,  65 
Barber's  palsy,  336 
Bateson,  19 
Bathing,  86 
Bayle,  215 
Beans,  33,  55,  62 

baked,  56,  61 
Bedbugs,  284 
Beef,  45,  52,  57,  64,  66,  68,  69,  72 

roast,  56 

steak,  56,  61,  65 
Beer,  34,  68,  118,  119,  123,  156 
Beets,  33 

Belgians,  rations  for,  55 
Belief,  religious,  3 
Belladonna  habit,  133 
Benzol,  340 
Beri-beri,  47,  48 
Berries,  34,  50 
Beverages,  35,  36 
Binet,  4 

Simon  scale,  14 
Birth,  records  of,  352,  353 
Bismuth,  51 
Black  death,  279 
Blackheads,  89 
Bladder,  175 

stones  in,  318 
Bleaching  powder,  323,  327 


Blending,  20 

Blindness,  21,  126,  139,  234,  261 
Blood,  4,  41,  79,  82-84,  87,  94,  96, 
100,  164,  168,  172,  174,  180, 
257,  273,  276,  277,  294,  349 
poison,  243 
pressure,  126,  128 
serum,  173 
stream,  144,  173 
transfusion  of,  24 
vessels,  84,  100 
Blue,  Dr.  Rupert,  281 
Boards  of  health,  292,  293,  346-351 
and  education,  350 
industrial  hygiene,  350 
infant  mortality,  350 
school  hygiene,  350,  351 
vital  statistics,  348 
functions  of, 

chemical  examination  by,  349 
control  of  communicable  disease 
by,  348,  349 
laboratory,  349 
sanitary  engineering,  348 
Bodington,  225 
Body,  composition  of,  26 
Boils,  92,  242,  243 
Borax,  310 
Boric  acid,  68 
Boston,  smallpox  in,  234 
Bottled  goods,  67 
Bowels,  45,  89 
Brain,  94,  96,  101,  232 
disease  of,  17 
injury  to,  17 
Brandy,  35,  115 
Brass,  343 

Bread,  31,  33,  45,  54-56,  58,  59 
Breakdown,  nervous,  60 
Breakfast  foods,  59,  61 
Breathing,  deep,  82,  83 
Breeding,  experiments  in,  6,  11 
Brehmer,  225 

Bright's  disease,  5,  131,  179,  297 
Brill's  disease,  282 
Bronchi,  339 
Bronchial  trouble,  838 
Bronchitis,  143,  339 


362 


INDEX 


Brown-tail  moth,  91 

Brack,  257 

Buccal  secretions,  211 

Bulk  of  food,  34,  45-46,  54,  58 

See  FOOD 
Burns,  228 

Butter,  31,  33,  44,  45,  55,  56,  59, 
61,  62,  71,  222,  223 

fat,  311 
Buttermilk,  311 

fad,  64 


CABBAGE,  34,  61 
Caffein,  28,  35,  36 
Caisson  disease,  80,  339 
Calcium,  28 

hypochlorite,  323 
Calomel,  145 
Calorie,  definition  of,  29 
Calorimeter,  25,  29 
Calves,  238 
Canadian  Royal  Commission,  101, 

102 
Cancer,  179,  301-304 

internal,  5 
Candy,  33,  65 
Canned  goods,  67 
Canning  food,  67,  68 
Cannon,  Walter  B.,  51 
Carbohydrates,   26,  29-34,  36,  42- 

47,  58,  59,  62,  74,  114 
Carbolic  acid,  163,  164,  167,  168 
Carbon,  74 

bisulphide,  343 

dioxide,  29,  74,  75,  80,  81,  84 

monoxide,  76 
Carbuncle,  92,  243 
Carriers, 

animals  as,  222 

cholera,  189,  191 

consumption,  222 

scarlet  fever,  206 

typhoid,  183,  184 

See  INFANTILE  PARALYSIS 
Carroll,  Dr.,  273 
Carrots,  27 


Casein,  30 
Castor  oil,  145 
Catarrh,  148,  149 
Cattle,  beef,  222 

dairy,  222 
Cauliflower,  34 
Caviar,  32 

Celery,  34,  46,  59,  61 
Cells,  white,  172 
Cellulose,  31,  34 
Cereals,  31,  33,  47,  57,  58,  62 

highly  milled,  48 
Cerebro-spinal-meningitis,  294 
Cesspools,  320,  329,  330,  346 
Chancre,  251-253,  257 
Chancroid,  250,  262,  263 

bacillus  of,  250,  263 
Chapin,  210,  211 
Characteristics,  acquired,  9,  21,  172 

inheritance  of,  10-12,  172 

See  HEREDITY 

unit,  18-20 

Cheese,  33,  45,  56,  59,  61,  62,  69 
Chemicals,  164 
Chemotherapy,  258 
Cherries,  34 
Chest,  pains  in,  227 
Chest  weights,  96 
Chicken,  56,  64 
Chickenpox,  195,  203,  207,  208,  210, 

294 

Childbed  fever,  155,  157,  243 
Child  labor,  104 
Children's  diseases,  146,  195 
Chocolate,  35,  36 
Chloride  of  lime,  323 
Chlorin,  323,  327 
Chlorine  gas,  76,  165,  340 
Chloroform,  117 

Cholera,  Asiatic,  71,  189-191,  192, 
193,  308,  317 

infantum,  308 

morbus,  192 
Chorea,  17 

Huntington's,  20 
Cigarette  smoking,  127,  128 
Cinchona  bark,  276 
Cities,  herding  in,  3 


INDEX 


363 


Cleanliness,  86,  88,  169,  184,  186, 

187,  244,  283 
of  milk,  312,  313 
and  red  flap,  91,  93 
and  warts,  91 
Cleft  palate,  17 
Climate,  28,  38,  81,  82,  85,  148 

in  tuberculosis,  226 
Clinical  tests,  98 
Clothing,  30,  85,  87,  92,  168 
Coal  tar  products,  129 
Cocaine,  129,  132,  133,  150 
Cocci,  160 
Cocoa,  35,  36 
Codeine,  132 
Codfish,  56,  61 
Coffee,  27,  28,  35,  54,  55,  66,  109, 

127 

Cold,  38,  66,  70,  77,  88 
Colds,   77,   83,   143,   171.   196-198, 

207-209,  213 
common,  144-146 
preventing  of,  197 
self-limited,  196 
See  COUGHS 
Cold  storage,  66,  69 
Colon  bacilli,  324 
Color-blindness,  17,  136 
Columbus,  250 
Communicable  disease,  4,  154-178, 

291-300,  326 
antitoxins  for,  173,  174 
bacteria  in,  160,  161 
bactericidal    substances    in,    174, 

175 
bacterial  toxins  or  poisons  in,  172, 

173 
characteristics  of  bacteria  in,  162, 

163 
classification  of  bacteria  in,  159, 

160 

control  of,  346,  347 
definition  of,  154 
destruction    of    bacteria    within 

body  in,  170 

without  body  in,  163-165 
early  history  of,  154,  155 
fumigation  in,  165,  166 


Communicable  disease,  general  con- 
siderations in,  291-300 

indirect  control  of  bacteria  in,  166, 
167 

methods  of  spread  of,  175-178 

Pasteur  and,  155-159 

practical  use  of  disinfectants  in, 
167-169 

prevention  of,  291-295 

protozoa  and  metazoa  in,  161,  162 

resistance  of  individuals  to,  170- 
172 

results  and  sequelae  of,  295-300 
Competition  in  exercise,  96 
Compression,  lung,  227 
Condiments,  35 
Conjunctivitis,  138 

gonorrheal,  138,  139 
Consanguinity,  21 
Constipation,  27,  46,  63,  89,  99,  130, 

145, 318 
Consumption,  40,  157,  214,  215 

and  climate,  81-82 

See  TUBERCULOSIS 
Consumptives,  home  care  of,  221, 

222,  228,  231 

Contact,  12,  177,  196,  210,  338 
Contact  diseases,  242-249 

hookworm,  248,  249 

local  sepsis,  242—244 

rabies,  245-248 

tetanus,  244,  245 

venereal  diseases,  250-270 
Contagion,  177 
Contagious,  150 

Cooking,  52,  53,  58,  68,  71,  72,  222 
Cooks,  habits  of,  184,  188 
Copper,  a  poison,  343 

sulphate,  165,  323,  327 
Corn,  47 

Corrosive  sublimate,  164 
Cortez,  233 
Cost  of  food,  53,  54 
Coughs,  220,  221,  227 

cigarette  smoker's,  127 

See  COLDS 

Cousins,  marriage  of,  20-22 
Cowpox,  155,  237,  238 


364 


INDEX 


Cows,  183,  237 

tuberculous,  223 

See  MILK 
Crackers,  55 

Cream,  33,  35,  44,  62,  311 
Crime,  122 

and  the  feeble  minded,  15 
Criminals,  122 
Cross-breeding,  21 
Croup,  179 

membranous,  198 
Cucumbers,  34 
Culex  mosquito,  276 
"Cure",  in  tuberculosis,  227 

D 

DANDBTTFF,  90 

Data,  experimental  in  heredity,  8-20 

Deaf  mutes,  21 

Deaf-mutism,  17 

Deafness,  147 

Death,  premature,  2 

rates  of  alcoholics,  121 
Deaths  in  U.  S.  A.,  1915,  2 
DeFoe,  155,  279 
Degenerative  diseases,  127 
Delirium  tremens,  121 
Dengue,  283,  284 
Depression,  Monday,  41 
Dermatitis,  91,  339 

See  SKIN 
Desires  of  man,  3 

sexual,  16 
Desserts,  sweet,  33 
Deterioration,  physical,  121 

mental,  121 

moral,  121 
Determiner,  19 
DeVries,  18 
Diabetes,  114,  179 
Diagnosis  in  tuberculosis,  220,  221, 

227,  230 
Diarrhea,  26,  51,  72,  179,  189,  191, 

192, 308,  318 
Diet,  23,  61,  89 

balanced,  33,  36,  37,  42-45,  62 

changes  in,  60 

experimental,  6 


Diet,  fish,  23 

general,  55-57 

home  made,  58 

in  leanness,  58-61 

in  obesity,  58-61 

monotonous,  51 

rice,  53 

scanty,  39 

special,  57,  58 

and  skin,  87,  88 

and  teeth,  142 
Disestion,  24,  26,  36,  37,  41 

disturbances  of,  52 

processes  of,  27,  52 
Digestive  diseases,  339 
Diphtheria,  115,  143,  146,  171,  172, 
174,  177,  179,  193,  198-203, 
211,  294,  308,  349 

antitoxin,  7,  157,  173,  175,  199- 

203,  209-211,  214,  352 
bacillus  of,  157 

carriers  of,  199,  202 

diagnosis  of,  199 

incubation  period  of,  199 

mortality  of,  199 
Dipsomania,  120-121 
Disease, 

availability  of  food  in,  87 

avoidance  of,  3,  24 

causation,  4 

children's,  146 

cure  of,  3 

infectious,  12 

laws  of,  1 

mysteries  of,  4 

of  eye,  138-140 

preventable,  2 

prevention  of,  2,  3 

resistance  to,  43 

and  alcohol,  121-122 

and  leanness,  40 

See    AIR-BORNE,    INSECT-BORNE, 
INGESTIVE,     CONTACT     DIS- 
EASES, COMMUNICABLE  DIS- 
EASES 
Disinfectants,    135,    163-165,    175, 

204,  207,  214,  232,  239 
practical  use  of,  167-169 


INDEX 


365 


Disinfection,  349 

Dissection  of  body,  4,  5 

Dissipation  and  tuberculosis,  224 

Dizziness,  137 

Dog  bite,  294 

Dogs  and  rabies,  245-248 

Dominance,  18,  19,  20 

Douches,  nasal,  149 

Drafts,  83,  145 

Dreams,  108,  109-112 

Drinking  cups,  common,  72,   196, 

253 
Droplets,   78,    143-145,     177,    193, 

195,  197,  203,  204,  207,  210, 

211,  218,  231,  233,  242,  288 
See  AIR-BORNE  DISEASES 
Drugs  88,   89,    109,    128,   130-132, 

220,  227,  249 
habit-forming,  132-134 
Drug  habitue's,  151 
Drunkard,  social,  120 
Drunkards,  224 
Drunkenness,  113,  118,  123 
Dum-dum  fever,  284 
Dust,  76,  78,  143,  145,  148 
Dusty  trades,  339 

and  tuberculosis,  229,  230 
Dwarfism,  19,  21 
Dysentery,  73,  191-194,  294,  317 
amoebic,  192 
bacillary,  191, 192 

E 

EARACHE,  147 
Ears,  254,  326 

hygiene  of,  143-149 
Ebers,  233 
Eberth,  180 

Echinococcus  disease,  193 
Eczema,  89-90 

Education,    function    of    board    of 
health,  350 

influence  on  environment,  80, 

See  SEX  HYGIENE 
Edwards,  Jonathan,  17 

family,  18 
Efficiency  and  fatigue,  103 


Eggs,   30,   32,  48,   50,   55,  61,    62, 
65,66 

in  tuberculosis,  226 

white  of,  44 

Ehrlich,  129,  172,  175,  258 
Eight-hour  day,  102,  103,  335,  336, 

344 

Elephantiasis,  283 
Emotions,  influence  of  food  on,  51, 52 

primitive,  121 

sex,  111 

Employers'  liability  laws,  333-335 
Employers  and  health,  106, 107 
Energy,  from  food,  23,  24,  26,  31, 
38,  45,  46,  59 

tabloid  of,  25 
Enteritis,  179 

Environment,  1,  9,  10,  11,  12,  15, 
21,  151,  152,  154 

accidents  of,  119 

and  occupation,  337,  338 
Epsom  salts,  130 
Ether,  117 

habit,  134 
Ethnoid  cells,  148 
Euphoria,  artificial,  116,  119 
Eustachian  tubes,  147 
Excess,  alcoholic,  88,  119,  120, 121 
Excreta,  4,  36,  182,  188,  324 

See  FECES 
Exercise,  10,  38,  83,  85,  94-100,  270 

amount  of,  99, 100 

competition  in,  96 

evils  of,  100 

habit  of,  99 

lack  of,  99 

of  everyday  life,  101 

of  teeth,  141 
Expectancy  of  life,  122 
Experimentation,  animal,  4,  6,  7, 11, 
215,  238-241 

on  dogs,  101 

on  pigeons,  101 

See  HORSES 
Experiments, 

in  food,  61 

on  plants,  11 

on  sleep,  107 


366 


INDEX 


Extractives,  32 

Eyes,  135-140,  254,  326 

black,  20 

blue,  12,  20 

cross,  136 

diseases  of,  138-140,  141,  294 

strain  of,  136, 137 

trouble  with,  104 


FACE,  87,  254 

lower,  141 

Factory  inspection,  344 
Faintness,  41 

See  ALCOHOL 
Families,  Edwards,  17, 18 
Jukes,  13 
Kallikak,  13, 14 
Farsightedness,  136 
Fasts,  experimental,  6,  26 
Fatigue,  51,  52,  96,  97,  100-104,  117, 
151,  153,  175,  225,  226,  230, 
270,  335,  336,  338 
excessive,  and  delirium,  150 
accidents,  104-107 
efficiency,  103,  104 
increased  infection,  107 
industry,  101-104 
poisons,  100 
Fats,  26,  29-34,  36-38,  40,  42-46, 

53,  54,  57,  59,  60,  99,  114 
of  skin,  85 
Fear,  nausea  of,  51 
Feces,  37,  44,  165,  167,  169,  180,  184 

See  WATER;   SEWAGE 
Feeble-minded,  crimes  of,  15 
Feeble-mindedness,  14-18,  20,  127, 

151,  268 
Feeding,  scientific,  24 

by  rectum,  24 
Fevers,  general,  227,  251 

See  YELLOW  FEVER,  TYPHUS 
FEVER,  RHEUMATIC  FEVER, 
etc. 

Filaria,  283,  284 
Filariasis,  283 
Filters,  household,  325, 326 


Filters,  rapid  sand,  322 

slow  sand,  322 
Filth  fever,  282 
Finger  nails,  87 
Fingers,  short,  17 

Fish,  30,  31,  32,  50,  64,  65,  68,  69, 
72 

diet,  23 

shell,  32 
Fission,  162 
Flat  feet,  336 
Fleas,  280,  281,  284 
Fletcherism,  so-called,  63,  64 
Flies,  182,  183,  186,  187,  189,  192, 

218,  284,  288,  328,  332 
Flour,  55,  61,  66 
Fluids,  59 
Flukes,  193 
Focus  of  disease,  176 
Food,  4,  23-73,  74,  85-87,  94,  141, 
143,  150,  154,  163-166,  175, 
182,  184,  187,  188,  192,  193, 
199,  218,  225,  242,  249,  253, 
288,  316,  347,  349. 

absorption  of,  39 

adulteration  of,  67 

alchohol  as,  114 

amount  of,  23,  37,  38 

analysis,  25,  26 

animal,  29,  31 

availability  of,  36,  37,  39 

balance  of,  23 

bland,  58 

bulk  of,  45,  46,  58,  63,  73 

combinations  of,  45 

composition  of,  355-357 

concentrated,  45 

conclusions,  concerning,  73 

cooking  of,  52 

cost  of,  53,  54 

drying,  68 

easily  digested,  58 

excess  of,  37,  38-41 

fads  and  fancies  in,  61 

improper,  145 

nitrogenous,  30 

oxidation  of,  23,  24,  25,  36 

predigested,  24,  65 


INDEX 


367 


Food,  preparation  of,  53 

preservation  of,  65-68 

preserved,  70 

serving  of,  53 

tabloid  of,  45 

transportation  of,  3 

values,  25,  29-30 

variety  of,  52 

vegetable,  33,  34 

and  bacteria,  69,  70 
conversation,  61 
disease,  71-73 
emotions,  51,  52 
Food  and  Drug  Act,  70,  132 
Foodstuffs,  26,  30,  33,  44 
Foot  and  mouth  disease,  307 
Formaldehyde  gas,  164, 166,  168, 175 
Formalin,  68,  164,  167,  168,  310 
Fowl,  Andalusian,  19 
Freud,  110,  111 
Fright,   cold  sweat  of,  85 
Fruits,  27,  46-48,  59,  68, 

sweet,  34 

Fuel,  26,  31,  42,  44,  45,  114 
Fumigation,  165, 166,  204,  209,  211- 
212,  274 

G 

GALLSTONES,  296,  318 
Games,  96,  97,  270 
Garbage,  165,  183,  187,  346 

disposal  of,  331,  332 
Gargles,  149 

Gastro-intestinal,   disturbances,   49, 
54 

tract,  341 
Genetics,  22 
Gerhard,  180 
German  measles,  294 
Germicides,  323 
Germs,  71,  73,  92,  146 

See    BACTERIA  ;     MICRO-ORGAN- 
ISMS 

Giantism,  19 
Gin,  35 

Glanders,  291,  294,  339 
Glands,  enlarged,  251 


Glasses,  137,  139,  140 

Globulins,  173 

Glucose,  32 

Gluten,  wheat,  30 

Goats,  194 

Goddard,  13 

Goitre,  319 

Gonococcus,  138,  161,  250,  260-262 

Gonorrhea,  138,  161,  171,  250,  260- 

262,  263,  264,  296,  299 
Gonorrheal,  conjunctivitis,  138,  139, 

261 

vaginitis,  261 
Gorgas,  Surgeon  General,  275,  277, 

351 

Gothenburg  system,  124 
Gout,  42,  43 
Grains,  33,  47,  62 
Grapefruit,  55 
Gregory  of  Tours,  233 
Grief,  influence  of,  52 
"Grippe",  198 
Guinea  pigs,  19,  20,  49,  257 
Gummata,  251 
Gums,  31 
Gymnasium  exercise,  96 

H 

HABIT,  ALCOHOL,  119,  120,  122 

food,  39,  58 
Habits,  good,  of  living,  21,  132 

individual,  39 

of  children,  211 

of  exercise,  99 

of  meals,  41,  42 

of  sleep,  108 

personal,  2 

race,  39 

sex,  266 

and  colds,  198 

mental  hygiene,  152, 153 
tuberculosis,  221,  224 
Habitue's,  drug,  16 

See  DRUGS,  HABIT-FORMING 
Haffkine,  281 
Hair,  12,  85,  89,  90 

dyes,  91 


368 


INDEX 


Hair  follicles,  89,  243 

Ham,  smoked,  68 

Hands,  87,  92,  184,  244,  254 

chapped,  88 

clean,  72,  166 

contaminated,  192 

washing  of,  188 
Hapsburg  chin,  inherited,  9 
Harrison  law,  132 
Hay  fever,  49,  50 
Hazen,  318,  331 
Headache  41,  80,  104,  129,  133,  134, 

137,  148 
Health,  insurance,  230 

laws  of,  1 

mysteries  of,  4 

of  the  individual,  1 

preservation  of,  2,  3 
Heart,  5,  26,  94,  95,  107,  147 

action,  87 

athletic,  97,  98 

diseases,  5, 127, 147,  205,  206,  256, 
261,  296,  297,  299,  300 

fatty  degeneration  of,  41 

tobacco,  126, 127 

Heat,  24,  25,  26,  29,  34,  38,  41,  43, 
77,  84,  85,  86,  87,  88,  94, 163, 
164 

extreme,  338 

and  bacteria,  322 
Heliotherapy,  135 
Hemorrhage,  79 
Hemophilia,  12,  17 
Heredity,  1,  6,  9-22,  90,  152 

and  alcohol,  122 
cancer,  302 
mental  disease,  151 
syphilis,  254,  255 
teeth,  142 
tuberculosis,  215 
Heroin,  132 
Hip-disease,  222 
Hippocrates,  154,  215,  225 
Hives,  49,  89 
Hoffmann,  251 
Hogs,  and  disease,  222 
Holmes,  Oliver  Wendell,  155 
Hookworm,  162,  193 


Hookworm,  disease,  248,249,  293, 
294,  328 

New  World,  249 

Old  World,  249 
Horses,  174,  201,  203,  232 

protein  of,  49 
Hospitals,  213 

feeding  in,  54 

insane,  255 

Rockefeller,  213 

tuberculosis,  219,  230,  232 

and  alcohol,  115 
Houses,  heating  of,  77 
Housing  and  tuberculosis,  228 
Humidity,  76-78,  82,  166,  338 
Humpback,  222 
Hunger,  41 
Hydatid  worms,  193 
Hydrophobia,  236,  245-248 
Hypersensitiveness  to  protein,  48 
Hypnosis,  110 


ICE,  183,  326 

Ice  water,  28 

Idiocy,  254 

Idiots,  14,  21 

Illness,  unnecessary,  2 

Illumination,  137-138 

Imbeciles,  14,  15 

"Immunes,"  yellow  fever,  273 

Immunity,  12,  170, 171 

in  diphtheria,  202 

side-chain  theory,  172 
Impressions,  prenatal,  12,  13 
Inactivity,  39 
Inbreeding,  20,  21 
Incidence,  of  infantile  paralysis,  286 

of  tuberculosis,  216,  217 

See  VARIOUS  DISEASES 
Incineration  of  garbage,  332 
Indian,  red  skin  of,  inherited,  9 
Industrial  hygiene,  350 
Infantile  paralysis,  158,  286-289 

carriers  of,  288 

incidence  of,  286 

mortality  of,  287 
Infantilism,  254 


INDEX 


369 


Infant  mortality,  308,  313-315,  350 

causes  of,  314 
Infection,  5,  72,  83,  87,  107 

air-borne,  144,  145,  169 
See  AIR-BORNE  DISEASES 

droplet  method,  78,  81 
See  DROPLETS 

mastoid,  148 

resistance  to,  170,  172,  196 

sinuses,  148 

spread  of,  196 

and  fatigue,  107 

teeth,  142 

Infections,  bovine,  223 
Influence,  post-natal 

See  ENVIRONMENT 
Influenza,  198 
Information,  sources  of,  4-8 
Ingestion,  177,  218 

diseases  transmitted  by,  179-194, 
197 

lead,  340 

Injuries,  traumatic,  151 
Inoculation,  6, 185, 186, 189,  236,  237 
Insane,  268 
Insanity,  17,  20,  21,  127,  151,  152 

lead,  341 
Insect-borne  diseases,  271-285 

bubonic  plague,  279-281 

caused  by  ticks,  284 

dengue,  283 

filariasis,  283 

Leischmaniasis,  284,  285 

malaria,  275-279 

sleeping  sickness,  283,  284 

typhus  fever,  281-283 

yellow  fever,  271-275 
Insects,  177,  288,  291 

in  communicable  disease,  154 
Insomnia,  109,  129,  133,  134 
Instability,  mental,  17 

nervous,  17 
Insurance,  health,  230 
Intestinal  tract,  45,  249,  297 
Ipecac,  193 
Iron,  28 
Irritation  of  skin,  339 

See  SKIN;  NOSE;   THROAT 


Isolation,  3,  177,  202,  209,  216,  232, 
239,  283,  288,  290,  349 

See  QUARANTINE 
Itch,  ground,  249 

"seven  years  ",  92,  93 


JACOBI,  ABRAHAM,  115 

Jail  fever,  282 

Jellies,  57 

Jenner,  155,  237 

Juices,   digestive,  50,  52,  65 

Jukes  family,  13, 14 

Jung,  110,  111 


KALA-AZAR   FEVER,    284 
Kallikak  family,  13, 14 
Kellicott,  17 
Kidneys,  27,  42,  147,  175,  296,  297 

as  food,  43 

disease,  205,  300,  344 

See  BRIGHT'S  DISEASE 
Kidney  stones,  318 
Knowledge,  medical,  source  of,  4 
Koch,  157,  189,  215,  217,  228 
Kolle,  185 
Koren,  119,  124 


LABORATORY,  a  function  of  board 
of  health,  349 

health,  220,  230 

mobile,  189 

Lactic  acid  bacilli,  64,  314 
Lactose,  32 
Laennec,  215 
La  Motte,  228 
Lard,  31,  55 
Laryngitis,  145 
Lassitude,  41 
Laundry,  machine,  834 
Law,  Harrison,  132 

Mendelian,  18-20 

Mosaic,  3 

See  PURE  FOOD 


370 


INDEX 


Laws,  of  disease,  1 

health,  1 

See  EMPLOYERS'  LIABILITY 
Lazear,  Dr.,  273 
Lead,  139,  150 

absorption  of,  340 

cramp,  341 

ingestion,  340 

inhalation  of,  340 

palsy,  341 

poisoning,  191,  319,  340-342,  353 
Leanness,  40 

diet  for,  58-61 

Legislation,  against  drink,  123 
Legumes,  33 

Leischman-Donovan  bodies,  284 
Leischmaniasis,  284,  285 
Lepers,  154,  289,  290 
Leprosy,  23,  158,  289,  290,  292,  294 
Lethargy,  39 
Lettuce,  46 
Lice,  93,  283,  284 
Life,  middle,  40 

preservation  of,  3 
Light,  135-140,  163 
Liqueurs,  35 
Liquors,  distilled,  35 
Lime,  164,  167 
Lister,  Lord,  157,  163 
Liver,  as  a  food,  43 

cirrhosis  of,  121 

gin  drinkers',  121 
Lobster,  61 
Lockjaw,  202,  244 

See  TETANUS 

Locomotor  ataxia,  252,  256 
Louis,  180 

Lumbar  puncture,  232,  233 
Lunches,  school,  53 
Lung,  compression,  227 
Lungs,  77,  82,  83,  84,  85,  94,  95,  171, 
215,  229,  339,  340 

See  TUBERCULOSIS 


M 


MACARONI,  45 
Macaulay,  234 


MacCorrison,  228 

MacKenzie,  Sir  James,  98 

Maize,  47 

Malaria,  82,  273-275,  284,  293,  294 

Mallory,  Dr.,  205 

Malnutrition,  142 

Malta  fever,  194,  291,  306 

Marius,  Bishop,  233 

Marriage,  of  cousins,  20-22 

and  syphilis,  259,  260,  270 
Massachusetts      State      Board      of 
Health,  238, 293, 321,  347, 349 
Mastication,  prolonged,  63 
Mastoid,  cells,  148 

infection,  148 
Masturbation,  267 
Meals,  87,  89 

number  of,  41, 42 

Measles,  143, 146,  161,  169,  170,  172, 
203-210,  231,  235,  240,  294 

carriers  of,  204 

German,  205 

immunity  to,  203 

incubation  period  of,  203 

rash  of,  203 

sequelae  of,  205 

similarity  of,  to  colds,  203 
Meat  30-32,  42,  45,  48,  52,  54,  58, 
59,  62,  66,  68 

fresh,  47 

red,  32,  64,  65 

white,  32,  64,  65 
Mediterranean  fever,  180 
Mendel,  18 
Mendelian  law,  18-20 
Meningitis,  cerebro-spinal,  231-233 
Meningococcus,  174,  231-233 
Mental  backwardness,  248 
Mental  disease,  inheritance  of,  151 
Mercury,  258 

bichloride  of,  164,  168 

salts  of,  164 
Metabolism,  6,  34,  88 

cycles  of,  74,  75 
Metal  trades,  334 
Metazoa,  159,  161, 162 
Metchnikoff,  64 
Micrococci,  160 


INDEX 


371 


Micro-organisms,  87 

classification  of,  159, 160 
Milk,  167,  169,  182,  183,  193,  194, 
199,  218,  219,  222,  223,  227, 
287,  291,  305-315 

adulteration  of,  311-313 

certified,  309 

condensed,  70 

cure,  59 

evaporated,  68,  70 

glass  of,  56,  57 

goats',  50 

in  food,  27,  29-33,  35,  36,  47, 
48,  50,  52,  55,  59,  61,  64,  66, 
68-72 

inspected,  309 

market,  309,  310 

pasteurized,  310,  311 

powdered,  70 

preservation  of,  310 

souring  of,  69,  310 

sterilized,  68 

sugar,  32 

and  bacteria,  305-310 

infant  mortality,  313-315 
Mind,  hygiene  of,  150-153 
Mineral  matter,  26,  28,  29,  46 
Mines,  335 
Miscarriage,  254 
Moisture,  66,  76,  77,  78,  81,  85,  165, 

186,  187,  195,  218 
Molds  of  skin,  88,  91,  93 
Monotony,  96,  102, 
Moron,  14,  15,  16 
Morphine,  132,  150 
Mosquitoes,  82,  165,  176,  273,  274, 

276,  277,  278,  283,  284, 
Mouth,  24,  25,  50,  63,  141,  143,  174, 
182,  192,  213,  214 

breathing,  146 
Mucous  membrane,  127,  148,  232- 

242,  252,  287 

Mumps,  203,  207,  208,  210,  294 
Mushrooms,  70 
Musical  talent,  inherited,  17 
Mustard,  35 

Mutilations,  gross  bodily,  12 
Myopia,  17 


N 

NASAL,  DISCHARGES,  167,  210 

secretions,  204,  207,  208,  210,  211, 

232 

Nausea,  44,  125,  126,  137 
Nearsightedness,  136 
Neisser,  257 
Nephritis,  144,  205,  206 
Nervous,  exhaustion,  102 

system,  84,  85,  97,  98,  101,  128, 

255,  256,  258,  341 
hygiene  of,  150-153 
Neuralgia,  42 
Neurasthenia,  226 
Nine-hour  day,  102 
Nitro-benzol,  343 
Nitrogen,  30,  36,  75,  76 
Noctural  emissions,  368 
Normal,  standards  for,  6 
Normality,  20 

Nose,  77,  141,  144,  146-148,  204- 
206,  208-210,  232,  287,  298, 
326,  332 

hygiene  of,  143-149 

irritation  of,  145 

and  nicotine,  126 
Nutrients,  53 

Nutrition,  10,  23,  26,  42,  58,  114, 
151 

processes  of,  24,  25 

and  cancer,  301 
Nuts,  31,  34 

O 

OBESITY,  34,  39-41,  99 

diet  in,  58-61 
Occupation    and  tuberculosis,   229, 

230 
Occupational  diseases,  333-345 

attitude  of  society  towards,  333 

classification  of,  334 

due  to  poisons,  342,  343 

hygienic     conditions     in     special 
trades  and,  338-340 

hygienic  environment  of,  337, 338 

lead  poisoning  in,  340-342 

special  strains  of,  336,  337 


372 


INDEX 


Odors,  79,  81 
Oil,  44,  59 

cod  liver,  60 

corn,  31 

olive,  31,  35 

of  skin,  88 
Old  age,  295 

premature,  255 

and  cancer,  302 
Oleomargarine,  71 
Onions,  34 

Opium,  129,  132,  133 
Orange  juice,  46 
Oranges,  34,  55,  56,  65 
Organized  labor,  106 
Organs,  excretory,  27 
Oriental,  eye  of,  inherited,  9 
Osier,  Sir  William,  179,  241 
Out-of-door  sleeping,  82 
Overcrowding,  221,  225,  230 
Overtraining,  197 
Ovum,  13 
Oxidation,  36 

See  FOOD 
Oxygen,  25,  74-76,  80,  81,  83,  84, 

162,  321 

Oysters,  183,  330 
Ozone,  79,  323,  327 


PALATE,  CLEFT,  17 
Paralysis,  343 

lead,  341 
Parasites,  52,  72,  82,  92,  175,  193, 

283 

Paratyphoid  fever,  71,  73,  189,  191 
Paresis,  general,  252,  255,  256,  258 
Parks,  225 
Parotid  gland,  207 
Parsnips,  33 
Partridge  poisoning,  70 
Pasteur,    155-157,    164,    235,    236, 

243,  246-248 

Pasteurization,  68,  156,  322 
Patent  medicines,  128-132 
Pathology,  cellular,  155 
Peanuts,  56,  61 


Peas,  33,  55,  56,  62 

Pea  soup,  56 

Peculiarities,  inherited,  9 

Pellagra,  47,  294,  348 

Pemmican,  68 

Pepper,  35 

Perspiration,  28,  85,  87,  100 

Pettenkoffer,  29 

Pfeiffer,  185 

Phagocytosis,  172 

Philip,  228 

Phosphorus,  28,  342 

"Phossy"  jaw,  342 

Phthisis,  214 

Physical  examination,  5,  6,  220 

Pie,  apple,  56 

Pimples,  88-90,  92,  242 

Pink  eye,  138 

Plague,  155, 

bubonic,  279-281,  284,  285,  291, 
292,  294,  347 

pneumonic,  171,  280 

septicemic,  280 
Plasmodia,  malarial,  276,  277 
Play,  94,  95 
Plums,  34 
Pneumococcus,  161,  171,   196,   212- 

214 

Pneumonia,  5,  115,  121, 122,  143, 
144,  161,  171,  179,  195,  205, 
212-214,  299,  314,  352 

crisis  in,  213 

death  rate  in,  212 

immunity  from,  213 

mortality  from,  212 

quarantine  in,  214 

self-limited,  212 

Poison,  34,  48,  88,  89,  124,  127, 
139,  150,  172,  173,  175,  204, 
295 

in  fatigue,  100 

ivy,  91 
Poisoning,  66,  67,  70,  71,  340,  342 

ptomaine,  72,  73 

sausage,  71 

See  LEAD 
Pork,  57,  72 

salt,  54 


INDEX 


373 


Post-mortem  examinations,  5 
Posture,  336,  337 
Potassium,  28 

bromide,  89 

iodide,  89,  238 
Potatoes,  33,  44,  56,  61 
Pott's  disease,  222 
Poverty,  53,  122,  123,  151,  152,  175, 
211,  225,  228,  229,  248,  314 
Predominance,  16 
Prenatal  clinics,  315 
Preservatives  in  food,  68 
Pressure,  osmotic,  29 
Prevention  of  disease,  176-178 
Privies,  328,  329 

sanitary,  249 

Prize-fighters  and  tuberculosis,  224 
Procedure,  therapeutic,  7 
Prohibition,  of  alcohol,  124,  125 
Prophylaxis,  medical,  263,  267 

See  VENEREAL  DISEASE 
Prostitutes,  16,  224,  253,  255,  264 
Proteins,  26,  29-32,  34,  36,  37,  42-46, 
49,  50,  54,    62,    64,    65,  73, 
75,  173 

foreign,  48,  49 
Protozoa,  159,  161, 162 
Puberty,  age  of,  89,  254 
Puerperal  fever,  155,  243 
Pulse,  acceleration  of,  126 
Pure  Food  Law,  71,  132 
Purgation,  58 
Pus,  164,  168,  306 
Pustules,  89 
Pyorrhea  alveolaris,  143 

Q 

"QUACKS",  131,  302 

Quarantine,  3,  146,  177,  200,  202, 
205-207,  209-211,  214,  232, 
239,  246-248,  290,  349 

Quinine,  89,  175,  276,  277,  278 

R 

RABBITS,  27,  245-248,  257 
Rabies,  236,  291,  294 


Radium,  302 
Ragweed,  49 
Ration,  balanced,  45 

daily,  46 

general,  54-57 
Rash,  measles,  203 

scarlet  fever,  206 

syphilis,  251 
Rats,  280,  281,  292 
Recession,  19 
Recreation,  95,  108,  225 

cure,  153 

indoor,  96 
Rectum,  24,  192 
"Red-flap",  91,  213 
Reduction,  refuse,  332 
Reed,  Dr.,  273 
Refuse,  disposal  of,  331,  332 
Registration  area,  2,  216,  217,  234, 

352 

Relapsing  fever,  284 
Remedies,  128 
Reservoirs,  321 
Resonance,  148 
Respiration,  74,  76,  84 
Respirators,  342,  343 
Respiratory,  disease,  314 

tract,  143,  144,  300 
Rest,  108 

cure,  153 

intervals,  105-106 
Rhazes,  233 
Rheumatic  conditions,  8 

fever,  144,  146,  171,  298,  299 
Rheumatism,  42,  64,  142,  298-300 

gonorrheal,  261 

infectious,  298 

metabolic,  298 
Rice,  diet,  53,  55 

polished,  47,  48 

whole,  47 
Rigg's  disease,  143 
Ringworm,  93,  161,  243 
Rocky  Mountain  spotted  fever,  284 
Roentgen  ray,  4 

See  X-RAY 
Roller  towel,  72 
Rolls,  Vienna,  55 


374 


INDEX 


Roots,  33 
Rowing,  98 
Rubner,  29 

Table  of,  30 
Running,  as  exercise,  96 


SACCHARINE,  65 

Safety,  margin  of,  39,  64 

Salad,  35 

dressings,  149 
Salicylic  acid,  68 
Salivary  gland,  207 
Salmon,  32 

Salt,  28,  29,  35,  46,  54,  55,  68 
Salt  rheum,  90 
Salts,  dose  of,  145 
Salvarsan,  129,  175,  258,  277 
Sanatoria,  feeding  in,  54,  225,  226, 

227,  230 

Sanitary  engineering,  348 
Sanitation,  municipal,  7 
Sausage,  71 

vegetable,  54 
Scabies,  93 

Scarlet  fever,  146,  161,  193,  195, 
203,  205-210,  231,  235,  240, 
294,  299,  308 

bacillus  of,  205 

carriers  of,  206 

quarantine  for,  207 

immunity  to,  206 

incubation  period  of,  205 

rash  of,  206 

sequelae,  205 

transmission  of,  206 
Schaudinn,  251 
Schick's  test,  202 
School,  hygiene,  350,  351 

open  air,  225 

lunches,  53,  54 

and  posture,  336,  337 
Science,  birth  of,  3 

engineering,  4,  7 

medical,  3,  4,  7 
Scrofula,  223 
Scurvy,  46 


Sebaceous  glands,  85-87,  89,  147 
Secret  nostrums,  128-132 
Segregation,  18 

of  consumptives,  221 
Self-limitation,  of  disease,  170,  181, 
212,  233 

colds,  197 

smallpox,  171,  210,  233 
Self-preservation,  instinct  of,  2,  3, 

263 

Senility,  early,  122 
Sensibilities,  finer,  121 
Sepsis,  general,  242-244 
Septic  sore  throat,  71,  193,  194,  295, 

306,  308 

Septum,  deviated,  144 
Sequelae,  colds,  144,  197 

measles,  204 

Serum,  174,  202,  214,  232,  233,  245, 
288 

sickness,  203 

Sewage,  165,  167,  182,  183,  187,  188, 
316-318,  320,  321 

disposal  of,  4,  328-332 
Sewer  gas,  78-80 
Sex,  16 

continence,  263,  266 

education  in,  268-270 

habits  of,  266,  267 

hygiene  of,  263-270 

impotence,  268 

inherited,  9 

instinct,  263 

organs  of,  251 

perversions,  267,  268 

and  dreams,  111 
Sexual  intercourse,   252,  261,    262, 

263,  264 
Shad,  53 
Shampooing,  90 
Sheep,  blood  of,  257 

protein,  49 
Shell-fish,  330 

See  FISH 

Shorter  hours,  102 
Signs,  5 

Sinuses,  148,  298 
"606",  129,258 


INDEX 


375 


Skin,  24,  49,  76,  94,  174,  177, 
193,  218,  219,  233,  242- 
244 

bathing  of,  87,  88 

disturbances  of,  89-93 

functions  of,  84-86 

irritation  of,  90,  92 

lesions  of,  93 

parasites  of,  87 

satiny,  88 

Sleep,  26,  107-109,  145 
Sleeping,  powders,  134 

sickness,  162,  283,  284 
Sleeplessness,  108,  109 
Slow  fever,  180 
"Slows",  306 

Smallpox,  143,  154,  155,  159,  168, 
195,  209,  233-241,  291,  295, 
346,  349,  353 

droplets  in,  233 

history  of,  233-235 

micro-organism  of,  233 

self-limited  disease,  233 
Smell,  sense  of,  79 
Smoking,  food,  68 

tobacco,  148 
Sneezing,  197 
Snow  blindness,  137 
Soap,  87,  88,  166 
Socialists,  11 
Soup,  27,  54,  56 

pea,  56 

tomato,  56 
Sour  milk  fad,  64 
Special  senses,  deterioration  of,  3 
Spectacles,  140 
Spermatozoon,  13 
Sphenoid  cells,  148 
Spinach,  46 
Spinal  cord,  232 
Spirillus,  161 
Spirochseta  pallida,   161,  175,  250- 

253,  257,  277 
Spitting,  197,  221 
Spontaneous  generation  of  disease, 

154 

Spores,  162, 
Sports,  95,  96 


Sputum,   167,   196,   210,   214,   219- 

221,  349 
Squab,  65 
Squirrels,  281 

Standards  of  food  requirements,  38 
Staphylococcus  aureus,  92,  242 
Starch,  36,  75 
Starvation,  partial,  64 
Statistics,  179,  209,  237,  239,  253, 
256 

of  accidents,  105 

alcohol,  113 

cancer,  301 

degenerative  diseases,  127 

longevity,  118 

morbidity,  4,  7,  8,  118 

mortality,  170,  216,  217 

tuberculosis,  221,  222,  229 

vital,  4,  7,  8,  230,  348-354 
Stegomyia  fasciata,  273,  276 
Sterility,  208,  262 
Sterilization,  16 

Stomach,  45,  101,  117,  128,  143 
Stools,  182,  183,  189,  349 
Strains,  occupational,  336,  337 
Strawberries,  56 
Strength,  loss  of,  43 
Streptococcus,  194,  306 
Stress  of  life,  152 
Stricture,  262 
String  beans,  337 
Strong,  282 
"Stuffing",  60 
Stupidity,  21,  127 
Stupor,  drunkenness,  115 

injury,  115 
Sugar,  31,  33,  35,  36,  55-57,  59,  62, 

65,  66,  68-70,  75 
Sugar  of  milk,  32 
Sulphate  of  aluminum,  322 
Sulphur,  28,  165,  274, 
Sunlight,  81,  82,  135,  137,  164,  212, 

321 
Superstitions,  3,  23,  28,  45,  65,  78, 

82,  91,  127,  145,  268 
Sweat,  85 

glands,  84,  85,  87 

shops,  337 


376 


INDEX 


Sweating,  26 
Sweetbreads,  43 
Swimming  pools,  326,  327 
Symptoms,  5 

Syphilis,  122,  151,  158,  161,  172, 
175,  238,  239,  243,  250-261, 
263,  264,  275,  292,  296,  349 

congenital,  254 

course  of,  251,  252 

dangerous  lesions  of,  252,  253 

effects  of,  255,  256 

frequency  of,  254,  255 

history  of,  250,  251 

inherited,  12,  254 

prevalence  of,  251 

therapeutic  agents,  258,  259 

transmission  by  indirect  contact, 
253 

treatment  and  cure  of,  256-258 

and  marriage,  259,  260 
Syrups,  33 


TABES,  252,  256,  291 
Tapeworm,  72,  193 
Taylor  and  efficiency,  106 
Tea,  27,  35,  54,  65,  66,  109 
Teeth,  63,  298,  299 

hygiene  of,  141-143 
Temperature  of  body,  84 
Tetanus,  174,  235,  244,  245,  295 
Texas  fever,  284 

Throat,  77,  141,  144,  146,  147,  163, 
204,  205,  207-210,  232,  298, 
300,  326,  332,  349 

hygiene  of,  143-149 

irritation  of,  145 
Thyroid  gland,  59 
Ticks,  284 
Tipplers,  120 
Tissue,  adipose,  31 

alcohol  as,  114 

building  material,  24,  31 

fat,  40,  58 

and  food,  24-26,  28-31,  34,  43 
Toast,  58 
Tobacco,  109,  125-128 


Tonsillitis,  143,  145,  296,  299 
Tonsils,  213,  298,  299,  300 
diseased,  146, 147 
enlarged,  144 

Towels,  91,  92,  138,  168,  196,  261 
Toxins,  172, 173 
Trachoma,  138,  299 
Tract,  digestive,  42,  58 
See  DIGESTION 
intestinal  37 

See  INTESTINAL 

Training,  in  environment,  10,  21 
Trembles,  306 
Trichina;,  162,  193 
Trichiniasis,  72 

Tropics,  commercial  value  of,  279 
Trudeau,  225 
Trypanosome,  162,  283, 
Tsetse  fly,  283,  284 
Tubercle,    bacillus,    157,    174,    196, 
214-216,  218-222,  228,  289, 
306,  349 
bovine,  222 
Tuberculin,  227 

test,  223,  224,  238,  306 
Tuberculosis,    5,    12,    71,    72,    143, 
157-159,   179,   193-195,  212, 
214-231,  250,  292,  296,  338, 
339,  349,  352-354 
age  incidence  of,  217 
bovine,  222,  291 

conclusions  concerning,  230,  231 
cost  of,  217,  218 
cure  of,  225-227 
diagnosis  of,  220,  221,  227,  230 
failure  to  diagnose,  219,  220 
frequency  of,  215,  216 
history  of,  215 
of  bones,  223 

glands  of  neck,  223 
intestines,  222 
joints,  222,  223 
peritoneum,  222 
spine,  222 
udder,  222,  223 
mortality  and  morbidity  statistics 

of,  216,  217 
prevention  of,  219-225 


INDEX 


377 


Tuberculosis,  sanatoria,  60 
transmission  of,  218,  219 
.  treatment  of,  225-227 
and  housing,  228,  229 
and  occupation,  229,  230 
Tuberculous,  meningitis,  222 

tramps,  227 
Tubers,  33 
Tumors,  301,  302 
Turkey,  56 
Turnips,  33 

Typhoid  fever,  5,  71,  72,  150,  167- 
169,  170,  171,  177-189,  191- 
193,  236,  282,  284,  291,  292, 
296,  308,  312,  317,  323,  326, 
330,  349,  352,  353 
carriers  of,  183,  184,  188,  189,  291 
causes  of,  180-182 
para,  189 

prevalence  of,  179,  180 
transmission  of,  182-184 
vaccination  or  inoculation,   187- 

189 
and  war,  184-187 

See  WAR 

"Typhoid  Mary",  183, 184 
Typhus  fever,  180,  281-285,  295 

U 

ULCERS,  262 
Undernutrition,  53. 

in  tuberculosis,  225 
United   States   Public   Health   Ser- 
vice, 47,  202,  238,  281,  347. 
Upper  Air  Passages,  hygiene  of,  143- 

149 

Uric  acid,  43 
Urination,  51 

Urine,  26,  28,  29,  36,  131,  167 
Urticaria,  49 
Urotropin,  175 


VACCINATION,    159,  171,    173,    187, 

209,  211,  235-241,  291, 
anti-,  238-241 


Vaccination,     German     experience 
with,  239,  240 

history  of,  235-238 

principle  of,  236,  237 

security  of,  238 

typhoid,  185,  186,  187-189,  291 
Vaccine,  cholera,  191 

colds,  196 

plague,  280 

pneumonia,  213 

smallpox,  7,  171,  349 

typhoid,  188,  349 
Variations  in  individuals,  39 
Variety,  in  food,  52 
Vaso-motor  system,  126 
Veal,  57 

Vegetables,  27,  30,  45,  47,  48,  53, 
54,  57,  62,  68 

green,  34,  46,  59 
Vegetarianism,  62,  63 
Vegetarians,  30 
Veins,  24,  174 

Venereal  disease,  117,  122,  250-270, 
292,  293,  354 

chancroid,  262,  263 

gonorrhea,  260-262 

sex  hygiene,  263-270 

syphilis,  250-260 
Ventilation,  81,  144 
Vinegar,  35 

Violet  rays,  164,  323,  327 
Virchow,  155 
Vision,  135,  136 
Vital  statistics  352-354 

See  STATISTICS 
Vitamins,  46-48,  52,  54,  310 
Voit,-  29 

W 

WAITERS,  336 
Walking,  as  exercise,  96 
Walnuts,  61 
War,  Afghan,  185 

Boer,  185,  187 

Civil,  184,  217 

European,    186,    187,    191,    239, 
245,  323,  328,  329 


378 


INDEX 


War,  Franco-Prussian,  184 

Russo-Japanese,  188 

sanitary  practice  in,  187 

Spanish-American,  67,  185 

and  typhoid,  184,  187 
Warts,  91 
Wassermann     reaction,     257,     258, 

260 
Waste,  body,  26,  94,  95 

economic,  123 

See  also  TUBERCULOSIS 
Water,  316-327 

bacteria  in,  317,  318 

bottled,  325 

ground,  320 

household  filters  for,  325,  326 

purification  of,  4,  321-324 

rain,  319,  320 

sources  of,  319-321 

surface,  320 

systems,  316,  317 

a  food,  24-29,  33,  46,  59,  65,  69- 
71,73 

and  cholera,  188-190 

communicable  disease,  166,  167, 
291 

disease,  317-319 

dysentery,  193 

hookworm  disease,  249 

milk,  308 

sewage,  328-331 

swimming  pools,  326 

the  skin,  84,  85,  88 

typhoid,  182,  183,  186,  187 
Waterhouse,  Benjamin,  237 
Weight,  excess  of,  41 

loss  of,  227 

reduction  of,  28,  260 

and  exercise,  94 
Whiskey,  35,  115,  129 


White  swelling,  222 

Whooping  cough,  143,  169,  195,  196, 

203,  208-210,  235,  295 
Widal  reaction,  180,  188 
Wines,  35,  69,  118,  119,  123,  156 
Wood  alcohol,  139,  343 
Work,  37-39,  45,  94,   100,  103,  151 

brain,  38,  103 

cure,  153 

day's,  95 

and  alcohol,  117 
consumption,  221 
worry,  102 
Worms,  159,  160,  162,  249 

hydatid,  193 

pin,  162 

See  HOOKWORM  ;  TAPEWORM 
Worry,  52,  151,  152,  153,  266 

and  work,  102 
Wounds,  243 
Wright,  185 
Writer's  cramp,  336 


X-RAY,  51,  98,  224,  302 


YEAST,  BREWER'S,  48 
Yellow  fever,  6,  82,  159,  161,  171, 
176,  271-277,  284,  285,  292, 
295 

cause  of,  273-274 
extent  of,  272 
history  of,  271-273 


ZEISS  LENS  Co.,  102,  103 
Zwiebach,  58 


This  book  is  DUE  on  the  last  date  stamped  below 


1931 


MAY  28  1 
5 


tPR  8     IS5* 

OCT  1  4  I960 
FEB  2  7  1961 

jj\N  1  4  1963 
L/ifl.K  £519651 


DEC12193J     ^    __0 


JUN  li  1935 

Mi,.** 

v*  Y  2  'i   134] 

Blrtl    .**  * 

IJUL  1*  194S 
«At  12-1 

Form  L-9-35m-8,'28 


MOV    4 1978 


UCSOUTHERNREG|ONALL=FACILTY 


A    001356684    9 


RA 

418 
L51h 


